Provider Demographics
NPI:1548394588
Name:GOLD, LISA ANN (DN)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:GOLD
Suffix:
Gender:F
Credentials:DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4305 N LINCOLN AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1711
Mailing Address - Country:US
Mailing Address - Phone:773-443-3132
Mailing Address - Fax:
Practice Address - Street 1:4305 N LINCOLN AVE
Practice Address - Street 2:SUITE F
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1711
Practice Address - Country:US
Practice Address - Phone:773-443-3132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2014-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL181000333172P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172P00000XOther Service ProvidersNaprapath
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001636607OtherBCBS OF ILLINOIS