Provider Demographics
NPI:1720139744
Name:BRAVERMAN, LISA J (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:J
Last Name:BRAVERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1075 BEECHER XING N STE A
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-4572
Mailing Address - Country:US
Mailing Address - Phone:614-475-6712
Mailing Address - Fax:614-475-6902
Practice Address - Street 1:1075 BEECHER XING N STE A
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-4572
Practice Address - Country:US
Practice Address - Phone:614-475-6712
Practice Address - Fax:614-475-6902
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062326207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0892815Medicaid
OH000000122408OtherANTHEM BCBS
OH0892815Medicaid
OH0730604Medicare ID - Type Unspecified