Provider Demographics
NPI:1881662153
Name:JARDINE, LISA M (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:JARDINE
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 1:635 1ST ST N
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4129
Mailing Address - Country:US
Mailing Address - Phone:863-294-0670
Mailing Address - Fax:863-298-3200
Practice Address - Street 1:450 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3050
Practice Address - Country:US
Practice Address - Phone:863-294-0670
Practice Address - Fax:863-298-3200
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76581207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL160044555OtherMEDICARE ID/RRM PIN
FL255262100Medicaid
FL160044555OtherMEDICARE ID/RRM PIN
FL255262100Medicaid