Provider Demographics
NPI:1013015817
Name:DIMARZIO, LISA A (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:DIMARZIO
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 1:2003 MEDICAL PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7992
Mailing Address - Country:US
Mailing Address - Phone:410-573-1110
Mailing Address - Fax:410-266-0714
Practice Address - Street 1:2003 MEDICAL PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401
Practice Address - Country:US
Practice Address - Phone:410-573-1110
Practice Address - Fax:410-266-0714
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD038158207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD093371600Medicaid
260077OtherMDIPA
0401156OtherUNITED HEALTHCARE
MD110060518OtherMEDICARE RAILROAD
P0409OtherPRINCIPLE
260077OtherMAMSI
4269169OtherAETNA
P11673OtherBCBS POINT OF SERVICE
1496254OtherUNITED MINE WORKERS ASSOC
MD52129501OtherBCBS
DC0001OtherBCBS
MD52129501OtherBCBS
MD093371600Medicaid