Provider Demographics
NPI:1659019644
Name:LIZARDO, DAN ANDREW
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:ANDREW
Last Name:LIZARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 ALEKSANDER LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT ROYAL
Mailing Address - State:NJ
Mailing Address - Zip Code:08061-1067
Mailing Address - Country:US
Mailing Address - Phone:856-332-9357
Mailing Address - Fax:
Practice Address - Street 1:1100 LAUREL OAK RD
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4363
Practice Address - Country:US
Practice Address - Phone:856-679-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ-Medicaid