Provider Demographics
NPI:1477850410
Name:CORTAZAR, LISSETTE D (MD)
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:D
Last Name:CORTAZAR
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 1:1250 ASTURIA AVE
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-4736
Mailing Address - Country:US
Mailing Address - Phone:786-205-4066
Mailing Address - Fax:347-493-3512
Practice Address - Street 1:3661 S MIAMI AVE STE 402
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-4230
Practice Address - Country:US
Practice Address - Phone:305-815-0055
Practice Address - Fax:347-493-3512
Is Sole Proprietor?:No
Enumeration Date:2011-02-25
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1299822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019445200Medicaid