Provider Demographics
NPI:1689674814
Name:LISCIANDRO, KELLY A (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:LISCIANDRO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HAGEN DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2658
Mailing Address - Country:US
Mailing Address - Phone:585-381-1440
Mailing Address - Fax:585-586-9108
Practice Address - Street 1:30 HAGEN DR
Practice Address - Street 2:SUITE 300
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2658
Practice Address - Country:US
Practice Address - Phone:585-381-1440
Practice Address - Fax:585-586-9108
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228369-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7441491OtherAETNA
NYP010228369OtherBLUE CHOICE
NY115965BJOtherPREFERRED CARE
NY02423485Medicaid
NYH81262Medicare UPIN
NYDD5136Medicare ID - Type Unspecified