Provider Demographics
NPI:1326047432
Name:HERON, LISMORE BURTON (MD)
Entity Type:Individual
Prefix:
First Name:LISMORE
Middle Name:BURTON
Last Name:HERON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 SE OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34996-2576
Mailing Address - Country:US
Mailing Address - Phone:772-781-0222
Mailing Address - Fax:772-781-0008
Practice Address - Street 1:1027 SE OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996-2576
Practice Address - Country:US
Practice Address - Phone:772-781-0222
Practice Address - Fax:772-781-0008
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0082280207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261960100Medicaid
FLME082280OtherMEDICAL LICENSE
FL1326047432Medicare NSC
FL261960100Medicaid
H36715Medicare UPIN
FL261960100Medicaid