Provider Demographics
NPI:1033153440
Name:FEDULLO, LISA M (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:FEDULLO
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 1:425 BRIGHTON ST
Mailing Address - Street 2:#303
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1273
Mailing Address - Country:US
Mailing Address - Phone:610-868-1100
Mailing Address - Fax:610-868-1111
Practice Address - Street 1:425 BRIGHTON ST
Practice Address - Street 2:#303
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-1273
Practice Address - Country:US
Practice Address - Phone:610-868-1100
Practice Address - Fax:610-868-1111
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD027576E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01208158Medicaid
E71365Medicare UPIN
PA01208158Medicaid