Provider Demographics
NPI:1376543660
Name:CHESTNUT, LISA D (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:D
Last Name:CHESTNUT
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 1:509 WESTON CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23238-5583
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4687 POUNCEY TRACT ROAD
Practice Address - Street 2:KIDMED
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5802
Practice Address - Country:US
Practice Address - Phone:804-422-5437
Practice Address - Fax:804-422-5438
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050845208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAF87004Medicare UPIN