Provider Demographics
NPI:1942241278
Name:BRUNDRETT, LISA KAY (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:KAY
Last Name:BRUNDRETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:KAY
Other - Last Name:GORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1851 WOOD GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-6329
Mailing Address - Country:US
Mailing Address - Phone:561-753-2899
Mailing Address - Fax:
Practice Address - Street 1:1021 N STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-5117
Practice Address - Country:US
Practice Address - Phone:561-333-9331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8290207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261717000Medicaid
FL02006OtherBLUECROSS BLUE SHIELD
FL261717000Medicaid
H46377Medicare UPIN