Provider Demographics
NPI:1518361385
Name:LIDET REAL CORPORATION
Entity Type:Organization
Organization Name:LIDET REAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DETOURNAY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:305-710-1971
Mailing Address - Street 1:1235 MARIPOSA AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-3252
Mailing Address - Country:US
Mailing Address - Phone:305-710-1971
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-710-1971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5133213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029750000Medicaid