Provider Demographics
NPI:1053317024
Name:GUIDICE, LISAMARIE (DPM)
Entity Type:Individual
Prefix:DR
First Name:LISAMARIE
Middle Name:
Last Name:GUIDICE
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 1:230 BEACH 102ND ST
Mailing Address - Street 2:SUITE 3B
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-2861
Mailing Address - Country:US
Mailing Address - Phone:718-318-2811
Mailing Address - Fax:718-318-7689
Practice Address - Street 1:230 BEACH 102ND ST
Practice Address - Street 2:STE 3B
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694
Practice Address - Country:US
Practice Address - Phone:718-318-2811
Practice Address - Fax:718-318-7689
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005314213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU65777Medicare UPIN
NY05560Medicare PIN