Provider Demographics
NPI:1548227937
Name:WALTERS, LISA A (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:WALTERS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3051 LONG BEACH RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572
Mailing Address - Country:US
Mailing Address - Phone:516-764-5142
Mailing Address - Fax:516-763-7420
Practice Address - Street 1:3051 LONG BEACH RD
Practice Address - Street 2:SUITE 6
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572
Practice Address - Country:US
Practice Address - Phone:516-764-5142
Practice Address - Fax:516-763-7420
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2009-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215984207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH09412Medicare UPIN