Provider Demographics
NPI:1497289607
Name:VISSERMAN, LAUREN FREDERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:FREDERIC
Last Name:VISSERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:LAUREN
Other - Middle Name:MICHELLE
Other - Last Name:FREDERIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:135 RUTLEDGE AVE FL 8
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-8903
Mailing Address - Country:US
Mailing Address - Phone:843-876-0888
Mailing Address - Fax:
Practice Address - Street 1:135 RUTLEDGE AVE FL 8
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-6773
Practice Address - Country:US
Practice Address - Phone:843-876-0888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2020-02548207Q00000X
390200000X
SCLL41118207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program