Provider Demographics
NPI:1245422666
Name:PUDUSSERI, LISA (DO)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PUDUSSERI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12255 S 80TH AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1284
Mailing Address - Country:US
Mailing Address - Phone:708-923-4200
Mailing Address - Fax:708-923-4201
Practice Address - Street 1:12255 S 80TH AVE STE 205
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1284
Practice Address - Country:US
Practice Address - Phone:708-923-4200
Practice Address - Fax:708-923-4201
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036135453207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-135453Medicaid
ILF400198461Medicare UPIN