Provider Demographics
NPI:1710929302
Name:ANDOLINA, LISA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:ANDOLINA
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 1:10 PINE HOLW
Mailing Address - Street 2:
Mailing Address - City:MENDON
Mailing Address - State:NY
Mailing Address - Zip Code:14506-9769
Mailing Address - Country:US
Mailing Address - Phone:585-905-4890
Mailing Address - Fax:
Practice Address - Street 1:10 PINE HOLW
Practice Address - Street 2:EMERGENCY
Practice Address - City:MENDON
Practice Address - State:NY
Practice Address - Zip Code:14506-9769
Practice Address - Country:US
Practice Address - Phone:585-905-4890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246515207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02933122Medicaid
NYRB6759 - BA0017 GRPMedicare PIN
NY02933122Medicaid