Provider Demographics
NPI:1801864749
Name:LISI, DAVID NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:NICHOLAS
Last Name:LISI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 FOSTER RD
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-5416
Mailing Address - Country:US
Mailing Address - Phone:607-785-0918
Mailing Address - Fax:
Practice Address - Street 1:33-57 HARRISON STREET
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790
Practice Address - Country:US
Practice Address - Phone:607-763-6104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1280242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00553324Medicaid
E37006Medicare UPIN
NY52019DMedicare ID - Type Unspecified