Provider Demographics
NPI:1780669119
Name:WISOTSKY, LISA (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:WISOTSKY
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 1:15 ENGLE ST
Mailing Address - Street 2:STE 205
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2927
Mailing Address - Country:US
Mailing Address - Phone:201-567-2277
Mailing Address - Fax:201-567-7506
Practice Address - Street 1:15 ENGLE ST
Practice Address - Street 2:STE 205
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2927
Practice Address - Country:US
Practice Address - Phone:201-567-2277
Practice Address - Fax:201-567-7506
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA62845208100000X
NY186896 1208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD06792300OtherCDS
NJD06792300OtherCDS
F97512Medicare UPIN
805467BPVMedicare ID - Type Unspecified