Provider Demographics
NPI:1457479123
Name:DURSO, LISA ROSE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ROSE
Last Name:DURSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E 64TH ST
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-7071
Mailing Address - Country:US
Mailing Address - Phone:212-585-3668
Mailing Address - Fax:212-288-7796
Practice Address - Street 1:115 E 64TH ST
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-7071
Practice Address - Country:US
Practice Address - Phone:212-585-3668
Practice Address - Fax:212-288-7796
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY201203207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY646L71Medicare PIN