Provider Demographics
NPI:1780812735
Name:NEAVYN, LISA N (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:N
Last Name:NEAVYN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:NICOLE
Other - Last Name:FREDIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 LOWELL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2792
Mailing Address - Country:US
Mailing Address - Phone:207-774-8277
Mailing Address - Fax:207-523-5310
Practice Address - Street 1:15 LOWELL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2792
Practice Address - Country:US
Practice Address - Phone:207-774-8277
Practice Address - Fax:207-523-5310
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA253205207W00000X
MEMD24235207W00000X
MI4301094262207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology