Provider Demographics
NPI:1013028844
Name:DIMEDIO, LISA CARLENE (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:CARLENE
Last Name:DIMEDIO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 HURFFVILLE CROSSKEYS RD BLDG 2
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-3552
Mailing Address - Country:US
Mailing Address - Phone:844-542-2273
Mailing Address - Fax:
Practice Address - Street 1:354 HURFFVILLE CROSSKEYS RD BLDG 2
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-3552
Practice Address - Country:US
Practice Address - Phone:844-542-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06370800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7042205Medicaid
NJ193534ZGH1Medicare PIN
NJG30981Medicare UPIN