Provider Demographics
NPI:1598722621
Name:COSGROVE, LISA A (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:COSGROVE
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 541216
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32954-1216
Mailing Address - Country:US
Mailing Address - Phone:321-452-1061
Mailing Address - Fax:321-453-0866
Practice Address - Street 1:270 N SYKES CREEK PKWY
Practice Address - Street 2:UNIT 108
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953
Practice Address - Country:US
Practice Address - Phone:321-452-1061
Practice Address - Fax:321-453-0866
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59169208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372574000Medicaid
FL18653OtherBLUE CROSS BLUE SHIELD FL
FL18653OtherBLUE CROSS BLUE SHIELD FL
FL372574000Medicaid