Provider Demographics
NPI:1164539011
Name:LAMBERT, LISE M
Entity Type:Individual
Prefix:
First Name:LISE
Middle Name:M
Last Name:LAMBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 N OCEAN BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-6420
Mailing Address - Country:US
Mailing Address - Phone:954-564-1330
Mailing Address - Fax:954-564-0538
Practice Address - Street 1:4004 N OCEAN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-6420
Practice Address - Country:US
Practice Address - Phone:954-564-1330
Practice Address - Fax:954-564-0538
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME40766207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379292700Medicaid
FLF41386Medicare UPIN
FL379292700Medicaid