Provider Demographics
NPI:1619933058
Name:MOONEY, LISA KOEHL (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:KOEHL
Last Name:MOONEY
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 725
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-0725
Mailing Address - Country:US
Mailing Address - Phone:607-433-1792
Mailing Address - Fax:607-433-6608
Practice Address - Street 1:125 MAIN ST
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-2531
Practice Address - Country:US
Practice Address - Phone:607-433-1792
Practice Address - Fax:607-433-6608
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207806208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01761971Medicaid
NYF78885Medicare UPIN
NY01761971Medicaid