Provider Demographics
NPI:1215024393
Name:IPP, LISA S (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:IPP
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:PO BOX 29234
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-9234
Mailing Address - Country:US
Mailing Address - Phone:212-774-7182
Mailing Address - Fax:212-746-7481
Practice Address - Street 1:535 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4823
Practice Address - Country:US
Practice Address - Phone:212-774-7182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213819207RA0000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02281001Medicaid