Provider Demographics
NPI:1619970597
Name:CHAMPOUX-RHODEN, LISA (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:CHAMPOUX-RHODEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:CHAMPOUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2995 DREW ST FL 2
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-532-1355
Mailing Address - Fax:813-635-2613
Practice Address - Street 1:2470 BLOOMINGDALE AVE STE 223
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-6403
Practice Address - Country:US
Practice Address - Phone:813-689-7139
Practice Address - Fax:813-443-8157
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70484208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251446000Medicaid
FL32135Medicare PIN
FLG36525Medicare UPIN