Provider Demographics
NPI:1528027067
Name:LISANN, NEAL M (MD)
Entity Type:Individual
Prefix:DR
First Name:NEAL
Middle Name:M
Last Name:LISANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9520 63RD RD STE H
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1145
Mailing Address - Country:US
Mailing Address - Phone:718-755-0656
Mailing Address - Fax:866-310-5525
Practice Address - Street 1:9520 63RD RD STE H
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1145
Practice Address - Country:US
Practice Address - Phone:718-755-0656
Practice Address - Fax:866-310-5525
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1516662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00932009Medicaid
NY0232ADMedicare PIN
NY00932009Medicaid