Provider Demographics
NPI:1467981779
Name:BEDFORD, LISA M (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:BEDFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:DAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1740 E PARIS AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6204
Mailing Address - Country:US
Mailing Address - Phone:616-949-5600
Mailing Address - Fax:
Practice Address - Street 1:1740 E PARIS AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6204
Practice Address - Country:US
Practice Address - Phone:616-949-5600
Practice Address - Fax:616-949-6571
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301505079207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty