Provider Demographics
NPI:1578094660
Name:TISHBERG, LINDSAY
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:
Last Name:TISHBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 UNION ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-1210
Mailing Address - Country:US
Mailing Address - Phone:908-247-0512
Mailing Address - Fax:
Practice Address - Street 1:26901 76TH AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1433
Practice Address - Country:US
Practice Address - Phone:718-470-7640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3033802080P0204X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty