Provider Demographics
NPI:1073686234
Name:PATTANAYAK, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PATTANAYAK
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 1:1106 LUCERNE TER
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1017
Mailing Address - Country:US
Mailing Address - Phone:407-316-8898
Mailing Address - Fax:407-540-0773
Practice Address - Street 1:1106 LUCERNE TER
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1017
Practice Address - Country:US
Practice Address - Phone:407-316-8898
Practice Address - Fax:407-540-0773
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82411207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL06054OtherBCBS OF FLORIDA
FL6606532001OtherCIGNA HEALTHCARE
06054YMedicare ID - Type Unspecified
H49333Medicare UPIN