Provider Demographics
NPI:1821066853
Name:HARSTON-LEDOUX, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HARSTON-LEDOUX
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 1:37595 7 MILE RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1003
Mailing Address - Country:US
Mailing Address - Phone:734-432-7713
Mailing Address - Fax:734-432-7774
Practice Address - Street 1:37595 7 MILE RD
Practice Address - Street 2:SUITE 240
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1003
Practice Address - Country:US
Practice Address - Phone:734-432-7713
Practice Address - Fax:734-432-7774
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073153207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4619193Medicaid
N91620042Medicare ID - Type Unspecified
F87077Medicare UPIN