Provider Demographics
NPI:1134139710
Name:GUALBERTI-GIRGIS, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GUALBERTI-GIRGIS
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 1:9 PROFESSIONAL CIR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLTS NECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07722-2426
Mailing Address - Country:US
Mailing Address - Phone:732-431-1520
Mailing Address - Fax:732-431-1567
Practice Address - Street 1:9 PROFESSIONAL CIR
Practice Address - Street 2:SUITE 101
Practice Address - City:COLTS NECK
Practice Address - State:NJ
Practice Address - Zip Code:07722-2426
Practice Address - Country:US
Practice Address - Phone:732-431-1520
Practice Address - Fax:732-431-1567
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA068540207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9073001Medicaid
NJ201045876OtherTAX IDENTIFICATION NUMBER
NJ067315S92Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NJG81447Medicare UPIN