Provider Demographics
NPI:1982670626
Name:ERCOLINI-BHATIA, LISA M (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:ERCOLINI-BHATIA
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 1:136 N THIRD ST
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-7002
Mailing Address - Country:US
Mailing Address - Phone:805-736-1253
Mailing Address - Fax:806-736-3193
Practice Address - Street 1:136 N THIRD ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-7002
Practice Address - Country:US
Practice Address - Phone:805-736-1253
Practice Address - Fax:806-736-3193
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC54110207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ37313ZMedicaid
CAW253Medicare PIN