Provider Demographics
NPI:1538118435
Name:GRUSON, LISA MOED (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MOED
Last Name:GRUSON
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 1:330 E 70TH ST
Mailing Address - Street 2:APT 5D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-8634
Mailing Address - Country:US
Mailing Address - Phone:917-647-8112
Mailing Address - Fax:
Practice Address - Street 1:7901 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3957
Practice Address - Country:US
Practice Address - Phone:718-791-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229198207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology