Provider Demographics
NPI:1194933861
Name:EDSALL, LISA CSEH (MD, PHD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:CSEH
Last Name:EDSALL
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 CONCOURSE BLVD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5643
Mailing Address - Country:US
Mailing Address - Phone:804-549-4030
Mailing Address - Fax:804-549-4032
Practice Address - Street 1:320A CHARLES H DIMMOCK PKWY
Practice Address - Street 2:SUITE 7
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2917
Practice Address - Country:US
Practice Address - Phone:804-526-7364
Practice Address - Fax:804-526-7394
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241020207N00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program