Provider Demographics
NPI:1932211000
Name:BOOTSTAYLOR, LISA BRITTANY (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:BRITTANY
Last Name:BOOTSTAYLOR
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 1:550 PEACHTREE ST NE
Mailing Address - Street 2:STE 1480
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2247
Mailing Address - Country:US
Mailing Address - Phone:404-240-2804
Mailing Address - Fax:404-240-2805
Practice Address - Street 1:550 PEACHTREE ST NE
Practice Address - Street 2:STE 1480
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2247
Practice Address - Country:US
Practice Address - Phone:404-240-2804
Practice Address - Fax:404-240-2805
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045402174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG87806Medicare UPIN
GA24BCBQVMedicare ID - Type Unspecified