Provider Demographics
NPI:1023015963
Name:VINOKUR, LISA A (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:VINOKUR
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 1:3400 OLD MILTON PKWY
Mailing Address - Street 2:SUITE C585
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4434
Mailing Address - Country:US
Mailing Address - Phone:770-754-4445
Mailing Address - Fax:770-754-4449
Practice Address - Street 1:3400 OLD MILTON PKWY
Practice Address - Street 2:SUITE C585
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4434
Practice Address - Country:US
Practice Address - Phone:770-754-4445
Practice Address - Fax:770-754-4449
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2011-11-23
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
GA038394174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA002095813BMedicaid
GA52473770OtherBLUE CROSS BLUE SHIELD
GA16BDGDRMedicare ID - Type Unspecified