Provider Demographics
NPI:1346287844
Name:GESUALDO, LISA (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:GESUALDO
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 1:1049 IRWINS CHOICE
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-2507
Mailing Address - Country:US
Mailing Address - Phone:410-420-1890
Mailing Address - Fax:
Practice Address - Street 1:900 CATON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5201
Practice Address - Country:US
Practice Address - Phone:410-368-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD56228207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD60609101OtherBLUE CROSS
MD147600900Medicaid
MD60609101OtherBLUE CROSS
MD244160ZDDBMedicare PIN
MD344563YWV2Medicare PIN
MDOTH000Medicare UPIN