Provider Demographics
NPI:1053312892
Name:DICRISTOFARO, LISA (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:DICRISTOFARO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:DICRISTOFARO-BOGAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:12000 MCCRACKEN RD
Mailing Address - Street 2:SUITE 550
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2964
Mailing Address - Country:US
Mailing Address - Phone:216-581-8369
Mailing Address - Fax:216-663-0666
Practice Address - Street 1:12000 MCCRACKEN RD
Practice Address - Street 2:SUITE 550
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2964
Practice Address - Country:US
Practice Address - Phone:216-581-8369
Practice Address - Fax:216-663-0666
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35078475207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2214544Medicaid
OHDI41037443Medicare ID - Type Unspecified
OHH29476Medicare UPIN