Provider Demographics
NPI:1316088644
Name:RANDON, LISA MARIE (MD)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:RANDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:HARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1511 BROOKLYN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-1007
Mailing Address - Country:US
Mailing Address - Phone:313-608-1510
Mailing Address - Fax:
Practice Address - Street 1:2395 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-1210
Practice Address - Country:US
Practice Address - Phone:313-831-2442
Practice Address - Fax:313-831-2442
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068207208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics