Provider Demographics
NPI:1629051651
Name:GAMELL, LISA S (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:GAMELL
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 1:3242 COVE BEND DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-2752
Mailing Address - Country:US
Mailing Address - Phone:813-265-6940
Mailing Address - Fax:813-908-3937
Practice Address - Street 1:3242 COVE BEND DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-2752
Practice Address - Country:US
Practice Address - Phone:813-265-6940
Practice Address - Fax:813-908-3937
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99976207WX0009X
FLME 99976207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11299OtherBLUE CROSS BLUE SHIELD
FL280206600Medicaid
FLAH941ZMedicare PIN