Provider Demographics
NPI:1114997616
Name:GONSALVES, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GONSALVES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 730729
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32173-0729
Mailing Address - Country:US
Mailing Address - Phone:386-231-3561
Mailing Address - Fax:386-677-6501
Practice Address - Street 1:335 CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 240
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-3181
Practice Address - Country:US
Practice Address - Phone:386-231-3561
Practice Address - Fax:386-677-6501
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0060521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372053500Medicaid
14099VMedicare ID - Type Unspecified
FL372053500Medicaid