Basic Information
| Provider Information | |||||||||
| NPI: | 1023015302 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLD | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | CAMILLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781076 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | 3178651479 | ||||||||
| Practice Location | |||||||||
| Address1: | 1141 S. INDIANA AVE. | ||||||||
| Address2: | |||||||||
| City: | CROWN POINT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2196620700 | ||||||||
| FaxNumber: | 2196620973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 03/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 01044839 | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200084250 | 05 | IN | MEDICAID |