Provider Demographics
NPI:1104185602
Name:ESTANISLAO, LISET (DO)
Entity Type:Individual
Prefix:
First Name:LISET
Middle Name:
Last Name:ESTANISLAO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 CHILDRENS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2664
Mailing Address - Country:US
Mailing Address - Phone:614-722-2000
Mailing Address - Fax:
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2664
Practice Address - Country:US
Practice Address - Phone:614-722-7859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-04
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.0130872080P0205X
OH34-013087208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0249386Medicaid