Provider Demographics
NPI:1184637159
Name:LUSIGNOLO, TINA M (MD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:M
Last Name:LUSIGNOLO
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 1:108 S RALEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08401-5822
Mailing Address - Country:US
Mailing Address - Phone:617-480-3032
Mailing Address - Fax:
Practice Address - Street 1:108 S RALEIGH AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-5822
Practice Address - Country:US
Practice Address - Phone:617-480-3032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2167102084P0800X, 2084F0202X, 2084P0015X
GA0578852084P0800X
CA543292084P0800X, 2084P0015X
OH35.1272202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAH83261Medicare UPIN
MAA35225Medicare PIN