Provider Demographics
NPI:1194568915
Name:GONDO, LISA TANYARADZWA (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:TANYARADZWA
Last Name:GONDO
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 1:3901 CHRYSLER DRIVE
Mailing Address - Street 2:SUITE 3B
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-577-7523
Mailing Address - Fax:
Practice Address - Street 1:3901 CHRYSLER DRIVE
Practice Address - Street 2:SUITE 3B
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-577-7523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-18
Last Update Date:2025-02-03
Deactivation Date:2025-01-31
Deactivation Code:
Reactivation Date:2025-02-03
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program