Provider Demographics
NPI:1275975161
Name:IUCCI, LISA DIANE (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIANE
Last Name:IUCCI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:DIANE
Other - Last Name:HARASYMCZUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:200 SCHULZ DR STE 2
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-6745
Mailing Address - Country:US
Mailing Address - Phone:327-426-3420
Mailing Address - Fax:732-747-2606
Practice Address - Street 1:4096 ENGLISH CREEK AVE
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-5746
Practice Address - Country:US
Practice Address - Phone:609-204-5357
Practice Address - Fax:609-272-7755
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB10400100208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0647276Medicaid