Provider Demographics
NPI:1023121183
Name:GABHART, LISA LEW (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:LEW
Last Name:GABHART
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:LEW
Other - Last Name:CHERUBIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5525 GROSSMONT CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3009
Mailing Address - Country:US
Mailing Address - Phone:858-499-2600
Mailing Address - Fax:
Practice Address - Street 1:5525 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3009
Practice Address - Country:US
Practice Address - Phone:858-499-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68275208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A682750Medicaid
CA00A682750Medicaid
CAWA68275AMedicare ID - Type Unspecified