Provider Demographics
NPI:1962675223
Name:KRANSDORF, LISA NGUYEN (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:NGUYEN
Last Name:KRANSDORF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:THAO
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8732
Mailing Address - Fax:
Practice Address - Street 1:200 MED PLAZA
Practice Address - Street 2:365 420 120
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024
Practice Address - Country:US
Practice Address - Phone:310-794-1276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ47273207R00000X, 208000000X
CAA111918208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ796979Medicaid
AZ796979Medicaid