Provider Demographics
NPI:1952301426
Name:DETOURNAY, LISA MARIE (DPM)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:DETOURNAY
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 1:1235 MARIPOSA AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-3252
Mailing Address - Country:US
Mailing Address - Phone:305-710-1971
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-710-1971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1933213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029750000Medicaid
T77541Medicare UPIN
FL65052Medicare ID - Type Unspecified