Provider Demographics
NPI:1508824657
Name:D'AMICO, LISA A (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:D'AMICO
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 1:820 PRUDENTIAL DR STE 713
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8209
Mailing Address - Country:US
Mailing Address - Phone:904-396-5682
Mailing Address - Fax:904-346-0864
Practice Address - Street 1:800 PRUDENTIAL DR
Practice Address - Street 2:EMERGENCY RESOURCES GROUP
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8202
Practice Address - Country:US
Practice Address - Phone:904-396-5682
Practice Address - Fax:904-346-0864
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89476207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL44055OtherBCBS
FL269935400Medicaid
GA970778487AMedicaid
GA970778487AMedicaid
FL44055AMedicare PIN
FL269935400Medicaid