Provider Demographics
NPI:1508866765
Name:TIRADO, LISSETTE E (DPM)
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:E
Last Name:TIRADO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 BEAVER RUIN RD NW
Mailing Address - Street 2:SUITE C
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3467
Mailing Address - Country:US
Mailing Address - Phone:770-935-4443
Mailing Address - Fax:770-935-4475
Practice Address - Street 1:625 BEAVER RUIN RD NW
Practice Address - Street 2:SUITE C
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3467
Practice Address - Country:US
Practice Address - Phone:770-935-4443
Practice Address - Fax:770-935-4475
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000729213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000761736AMedicaid
GAU59033Medicare UPIN
GA48SCCMVMedicare ID - Type Unspecified
GA000761736AMedicaid