Provider Demographics
NPI:1881038867
Name:MARTINS, LISDALIA R
Entity Type:Individual
Prefix:
First Name:LISDALIA
Middle Name:R
Last Name:MARTINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISDALIA
Other - Middle Name:R
Other - Last Name:LOPES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:509 6TH ST
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-2319
Mailing Address - Country:US
Mailing Address - Phone:631-239-1003
Mailing Address - Fax:
Practice Address - Street 1:509 6TH ST
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-2319
Practice Address - Country:US
Practice Address - Phone:631-239-1003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist