Provider Demographics
NPI:1508396730
Name:LISA THOMSEN MD INC A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LISA THOMSEN MD INC A PROFESSIONAL CORPORATION
Other - Org Name:LISA L. THOMSEN M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:L
Authorized Official - Last Name:THOMSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-963-4149
Mailing Address - Street 1:210 S GRAND AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4281
Mailing Address - Country:US
Mailing Address - Phone:626-963-4149
Mailing Address - Fax:626-963-9023
Practice Address - Street 1:210 S GRAND AVE STE 302
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4281
Practice Address - Country:US
Practice Address - Phone:626-963-4149
Practice Address - Fax:626-963-9023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63943261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care