Provider Demographics
NPI:1679577910
Name:VOLCKMAR, LISETTE (MD)
Entity Type:Individual
Prefix:
First Name:LISETTE
Middle Name:
Last Name:VOLCKMAR
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:P.O. BOX 8500-5365
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0001
Mailing Address - Country:US
Mailing Address - Phone:201-804-2800
Mailing Address - Fax:
Practice Address - Street 1:1200 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:ABINGTON
Practice Address - State:PA
Practice Address - Zip Code:19001-3720
Practice Address - Country:US
Practice Address - Phone:215-481-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD061023L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1642062Medicaid
PA906406Medicare ID - Type Unspecified
G51131Medicare UPIN