Provider Demographics
NPI:1750518460
Name:GRAHAM, LISA ELLEN (MSTOM)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ELLEN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MSTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5120 CARILLO ST
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2060
Mailing Address - Country:US
Mailing Address - Phone:305-740-5547
Mailing Address - Fax:
Practice Address - Street 1:6301 SUNSET DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4818
Practice Address - Country:US
Practice Address - Phone:305-669-2715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-20
Last Update Date:2009-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2651171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAP2651OtherACUPUNCTURE PHYSICIAN LICENSE