Provider Demographics
NPI:1255321576
Name:LISY, TODD A (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:A
Last Name:LISY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 MASSILLON RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-6400
Mailing Address - Country:US
Mailing Address - Phone:330-899-9350
Mailing Address - Fax:
Practice Address - Street 1:4880 S MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44319-4474
Practice Address - Country:US
Practice Address - Phone:330-644-2700
Practice Address - Fax:330-634-1329
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-075097207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2225372Medicaid
OHH32407Medicare UPIN
OH4043343Medicare PIN