Provider Demographics
NPI:1568425767
Name:ANDERSON, LISA L (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:ANDERSON
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:PO BOX 28082
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-8082
Mailing Address - Country:US
Mailing Address - Phone:212-987-3100
Mailing Address - Fax:
Practice Address - Street 1:425 W 59TH ST
Practice Address - Street 2:SUITE 9B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-8022
Practice Address - Country:US
Practice Address - Phone:212-523-7752
Practice Address - Fax:212-523-7731
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY162448-1207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00994289Medicaid
90D301Medicare ID - Type Unspecified
A64720Medicare UPIN