Provider Demographics
NPI:1295729341
Name:BROWN, LISA MALLOY (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MALLOY
Last Name:BROWN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 880
Mailing Address - Street 2:
Mailing Address - City:MONTROSS
Mailing Address - State:VA
Mailing Address - Zip Code:22520-0880
Mailing Address - Country:US
Mailing Address - Phone:804-493-9999
Mailing Address - Fax:804-493-7140
Practice Address - Street 1:18849 KINGS HWY
Practice Address - Street 2:
Practice Address - City:MONTROSS
Practice Address - State:VA
Practice Address - Zip Code:22520-2965
Practice Address - Country:US
Practice Address - Phone:804-493-9999
Practice Address - Fax:804-493-7140
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101226862207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010031605Medicaid
VA00V907D01Medicare ID - Type UnspecifiedPROVIDER NUMBER
VA010031605Medicaid