Provider Demographics
NPI:1962465641
Name:CHARLES, LISA-GAIL THOMAS (MD)
Entity Type:Individual
Prefix:MRS
First Name:LISA-GAIL
Middle Name:THOMAS
Last Name:CHARLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:LISA-GAIL
Other - Middle Name:SIMONE
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3083 SW 141ST TER
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-4678
Mailing Address - Country:US
Mailing Address - Phone:919-423-5455
Mailing Address - Fax:
Practice Address - Street 1:2950 CLEVELAND CLINIC BLVD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3609
Practice Address - Country:US
Practice Address - Phone:954-659-5883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057853207R00000X
NC117206207R00000X
FL131685207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine