Provider Demographics
NPI:1295268951
Name:SHAPIRO, LISA NICOLE (MS DO)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:NICOLE
Last Name:SHAPIRO
Suffix:
Gender:F
Credentials:MS DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 VILLAGE SQ APT 339
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2667
Mailing Address - Country:US
Mailing Address - Phone:631-374-4342
Mailing Address - Fax:
Practice Address - Street 1:101 SAINT ANDREWS LN
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2254
Practice Address - Country:US
Practice Address - Phone:516-674-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-09
Last Update Date:2020-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY306553207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program