Provider Demographics
NPI:1255306627
Name:DYNAN-DOBBERTIEN, LISA ANN (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:DYNAN-DOBBERTIEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 578
Mailing Address - Street 2:CLAY COUNTY HEALTH DEPARTMENT
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-0578
Mailing Address - Country:US
Mailing Address - Phone:904-529-2800
Mailing Address - Fax:904-529-2802
Practice Address - Street 1:3229 BEAR RUN BLVD
Practice Address - Street 2:CLAY COUNTY HEALTH DEPT -BLDG A
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065
Practice Address - Country:US
Practice Address - Phone:904-213-3202
Practice Address - Fax:904-272-4353
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6382207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377329900Medicaid
FL57115TMedicare PIN
FL377329900Medicaid
FL8483Medicare UPIN