Provider Demographics
NPI:1023110152
Name:JABLON, LISA K (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:JABLON
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 1:101 E OLNEY AVE
Mailing Address - Street 2:SUITE 505
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2421
Mailing Address - Country:US
Mailing Address - Phone:215-456-7000
Mailing Address - Fax:215-254-2599
Practice Address - Street 1:9880 BUSTLETON AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-2185
Practice Address - Country:US
Practice Address - Phone:215-676-2222
Practice Address - Fax:215-676-5923
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037734E2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1255425Medicaid
PA605016Medicare ID - Type Unspecified
PA1255425Medicaid