Provider Demographics
NPI:1265545313
Name:RICCIO, LISA L (DPM)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:RICCIO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2779
Mailing Address - Country:US
Mailing Address - Phone:631-351-3722
Mailing Address - Fax:631-385-1046
Practice Address - Street 1:325 PARK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2779
Practice Address - Country:US
Practice Address - Phone:631-351-3722
Practice Address - Fax:631-385-1046
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005238-1213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP1072042OtherOXFORD
NY6201199OtherGHI
NY2C5927OtherHEALTHNET
NYPA7731OtherBLUE CROSS/ BLUE SHIELD
NYP18751Medicare ID - Type Unspecified
NY2C5927OtherHEALTHNET