Provider Demographics
NPI:1063417798
Name:BROCKMAN, LISA A (DO)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3625
Mailing Address - Country:US
Mailing Address - Phone:310-632-0415
Mailing Address - Fax:310-639-2734
Practice Address - Street 1:3820 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3625
Practice Address - Country:US
Practice Address - Phone:310-632-0415
Practice Address - Fax:310-639-2734
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8065207R00000X
CA20A806208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA002A80650OtherMEDI CAL #
CA002A80650OtherMEDI CAL #