Provider Demographics
NPI:1134336100
Name:PETINIOT, LISA KAY (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:KAY
Last Name:PETINIOT
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 1:3333 BURNET AVE
Mailing Address - Street 2:ML 7015
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4266
Mailing Address - Fax:413-636-3549
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:ML 7015
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4266
Practice Address - Fax:413-636-3549
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.082974208000000X, 2080P0216X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX195229301Medicaid
TX8L0566Medicare PIN