Provider Demographics
NPI:1043219215
Name:DEBERNARDI, LISA A (DPM)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:DEBERNARDI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5108 HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-3113
Mailing Address - Country:US
Mailing Address - Phone:314-821-3668
Mailing Address - Fax:888-966-0079
Practice Address - Street 1:5108 HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-3113
Practice Address - Country:US
Practice Address - Phone:314-821-3668
Practice Address - Fax:888-966-0079
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004789213E00000X
MO2008030512213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004789Medicaid
MO1043219215Medicaid
IL1622982OtherBLUE CROSS / BLUE SHIELD
IL480014516OtherRAILROAD MEDICARE
MOP01302982OtherRAILROAD MEDICARE
ILF400118621Medicare PIN
MO149630007Medicare PIN
IL016004789Medicaid
IL1622982OtherBLUE CROSS / BLUE SHIELD
IL1277230001Medicare NSC