Provider Demographics
NPI:1033188669
Name:MAHONEY, LISA REEVES (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:REEVES
Last Name:MAHONEY
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 1:565 ROUTE 25A
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-2663
Mailing Address - Country:US
Mailing Address - Phone:631-821-9200
Mailing Address - Fax:631-821-3266
Practice Address - Street 1:565 ROUTE 25A
Practice Address - Street 2:SUITE 4
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-2663
Practice Address - Country:US
Practice Address - Phone:631-821-9200
Practice Address - Fax:631-821-3266
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY124569207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC05266Medicare UPIN
NY08A891Medicare ID - Type Unspecified