Provider Demographics
NPI:1710138755
Name:BRESLOW, LISA (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRESLOW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:MASCIANTONIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:390 VINEYARD WAY BLDG 500
Mailing Address - Street 2:SUITE 501
Mailing Address - City:WEST GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19390-8835
Mailing Address - Country:US
Mailing Address - Phone:610-869-0953
Mailing Address - Fax:610-869-5824
Practice Address - Street 1:390 VINEYARD WAY BLDG 500
Practice Address - Street 2:SUITE 501
Practice Address - City:WEST GROVE
Practice Address - State:PA
Practice Address - Zip Code:19390-8835
Practice Address - Country:US
Practice Address - Phone:610-869-0953
Practice Address - Fax:610-869-5824
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101025286207Q00000X
NJ25MB10740100207Q00000X
NY302800207Q00000X
VT032.0133896207Q00000X
TXS5130207Q00000X
PAOS018188207Q00000X
NC2020-00363207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031466770001Medicaid
PA523552ZCXXMedicare PIN