Provider Demographics
NPI:1407848682
Name:GWYNN, LISA (DO)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:GWYNN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4651 SHERIDAN ST.
Mailing Address - Street 2:SUITE #270
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-3422
Mailing Address - Country:US
Mailing Address - Phone:954-989-6000
Mailing Address - Fax:954-378-4775
Practice Address - Street 1:4651 SHERIDAN ST.
Practice Address - Street 2:SUITE #270
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-3422
Practice Address - Country:US
Practice Address - Phone:954-989-6000
Practice Address - Fax:954-378-4775
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0S8394208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262070700Medicaid
FL262070700Medicaid