Provider Demographics
NPI:1033613823
Name:LISAC, ROBERT RUDOLPH
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:RUDOLPH
Last Name:LISAC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 UPPERGATE DR #400
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-0001
Mailing Address - Country:US
Mailing Address - Phone:404-778-4834
Mailing Address - Fax:
Practice Address - Street 1:2015 UPPERGATE DR #400
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-6511
Practice Address - Country:US
Practice Address - Phone:404-778-4834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA880262080P0207X
FLTRN26672208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208000000XAllopathic & Osteopathic PhysiciansPediatrics