Provider Demographics
NPI:1710925367
Name:CODISPOTI, VICTORIA LISA (MD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LISA
Last Name:CODISPOTI
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 1:4030 CARTTER RD
Mailing Address - Street 2:
Mailing Address - City:KELL
Mailing Address - State:IL
Mailing Address - Zip Code:62853-1144
Mailing Address - Country:US
Mailing Address - Phone:618-548-2117
Mailing Address - Fax:618-548-0533
Practice Address - Street 1:3111 WILLIAMSON COUNTY PKWY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5235
Practice Address - Country:US
Practice Address - Phone:618-997-3645
Practice Address - Fax:618-998-1328
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE57011Medicare UPIN
ILK08396Medicare ID - Type UnspecifiedMEMBER NUMBER