Provider Demographics
NPI:1609868314
Name:PATHAK, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PATHAK
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 1:1592 ROUTE 739
Mailing Address - Street 2:
Mailing Address - City:DINGMANS FERRY
Mailing Address - State:PA
Mailing Address - Zip Code:18328-3477
Mailing Address - Country:US
Mailing Address - Phone:570-828-8000
Mailing Address - Fax:570-828-6928
Practice Address - Street 1:1592 ROUTE 739
Practice Address - Street 2:
Practice Address - City:DINGMANS FERRY
Practice Address - State:PA
Practice Address - Zip Code:18328-3477
Practice Address - Country:US
Practice Address - Phone:570-828-8000
Practice Address - Fax:570-828-6928
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD423073207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019656260004Medicaid
PA0019656260004Medicaid