Provider Demographics
NPI: | 1376658500 |
---|---|
Name: | ZAPOTOCKY, LISA C (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | LISA |
Middle Name: | C |
Last Name: | ZAPOTOCKY |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | LISA |
Other - Middle Name: | C |
Other - Last Name: | ALLSHOUSE |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | MD |
Mailing Address - Street 1: | 9485 MENTOR AVENUE |
Mailing Address - Street 2: | SUITE 210 |
Mailing Address - City: | MENTOR |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 44060 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 440-205-5877 |
Mailing Address - Fax: | 440-205-5735 |
Practice Address - Street 1: | 9485 MENTOR AVE STE 210 |
Practice Address - Street 2: | |
Practice Address - City: | MENTOR |
Practice Address - State: | OH |
Practice Address - Zip Code: | 44060-8723 |
Practice Address - Country: | US |
Practice Address - Phone: | 440-205-5877 |
Practice Address - Fax: | 440-205-5744 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-20 |
Last Update Date: | 2021-03-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | 35081768 | 207RA0000X |
OH | 35.081768 | 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 207RA0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Adolescent Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 2352350 | Medicaid | |
OH | 2352350 | Medicaid |