Provider Demographics
NPI:1659398493
Name:WEDDERBURN, LISA MICHELLE (DPM)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MICHELLE
Last Name:WEDDERBURN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 E 51ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-5902
Mailing Address - Country:US
Mailing Address - Phone:917-991-1279
Mailing Address - Fax:877-868-8633
Practice Address - Street 1:2146 BEVERLEY RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-5406
Practice Address - Country:US
Practice Address - Phone:718-210-3296
Practice Address - Fax:877-868-8633
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005519213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02321319Medicaid
NY02519726Medicaid
NY02321319Medicaid
NYN005519Medicare UPIN
NYPQW201Medicare PIN
NY02519726Medicaid
NY05451Medicare PIN