Provider Demographics
NPI:1952309924
Name:MENILLO, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MENILLO
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 1:1301 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-4776
Mailing Address - Country:US
Mailing Address - Phone:860-589-4501
Mailing Address - Fax:860-589-4502
Practice Address - Street 1:1301 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-4776
Practice Address - Country:US
Practice Address - Phone:860-589-4501
Practice Address - Fax:860-589-4502
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030842208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001308429Medicaid
CT370001044Medicare ID - Type Unspecified
CT001308429Medicaid