Provider Demographics
NPI:1205242765
Name:BRESHEARS, LISA DOAN (DPM)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DOAN
Last Name:BRESHEARS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:DOAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:299 W FOOTHILL BLVD STE 124
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3854
Mailing Address - Country:US
Mailing Address - Phone:909-946-6643
Mailing Address - Fax:909-946-6130
Practice Address - Street 1:299 W FOOTHILL BLVD STE 124
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3854
Practice Address - Country:US
Practice Address - Phone:909-946-6643
Practice Address - Fax:909-946-6130
Is Sole Proprietor?:No
Enumeration Date:2014-07-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5372213E00000X, 213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine