Provider Demographics
NPI:1467451823
Name:MEDVETZ, LISA ANN (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:MEDVETZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 GROVE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HADDON HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08035-1761
Mailing Address - Country:US
Mailing Address - Phone:856-796-9200
Mailing Address - Fax:856-796-9397
Practice Address - Street 1:1113 HOSPITAL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-1103
Practice Address - Country:US
Practice Address - Phone:609-835-5821
Practice Address - Fax:609-835-5827
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD060721-L207QA0401X
KY51460208600000X
PAMD060721L208600000X
IDM-13032208600000X
NJ25MA06954000208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA113499OtherBCBS
PA0017932090008Medicaid
NJ8239606Medicaid
PA038172VGUMedicare PIN
NJ8239606Medicaid
H16617Medicare UPIN