Provider Demographics
NPI:1639680614
Name:GILLIS, LISA JANE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:JANE
Last Name:GILLIS
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 1:601 5TH ST S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4804
Mailing Address - Country:US
Mailing Address - Phone:727-767-8491
Mailing Address - Fax:
Practice Address - Street 1:601 5TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4804
Practice Address - Country:US
Practice Address - Phone:727-767-8491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC152190207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)