Provider Demographics
NPI:1447318985
Name:FINE, LISA ELLEN (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ELLEN
Last Name:FINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ELLEN
Other - Last Name:FINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:11080 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1937
Mailing Address - Country:US
Mailing Address - Phone:310-966-6500
Mailing Address - Fax:310-473-0831
Practice Address - Street 1:11080 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1937
Practice Address - Country:US
Practice Address - Phone:310-966-6500
Practice Address - Fax:310-473-0831
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 730162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG73016OtherMEDICAL LICENSE NO
CABF3346384OtherDEA
CAWG73016CMedicare UPIN
CAG25371Medicare ID - Type UnspecifiedMEDICARE PROV NO.