Provider Demographics
NPI:1336231844
Name:BEVILACQUA, LISA R (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:R
Last Name:BEVILACQUA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:1882 NEW SCOTLAND RD STE 200
Practice Address - Street 2:
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159-3627
Practice Address - Country:US
Practice Address - Phone:518-439-2460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191889207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01495192Medicaid
NY08954OtherMVP
NY200032OtherSENIOR WHOLE HEALTH
NY52558OtherGHI/HMO
NY10005959OtherCDPHP
NY000401405003OtherBSNENY
NY040824000041OtherFIDELIS
NY4725D1OtherEMPIRE BC
NY531715OtherAETNA
NYF87069Medicare UPIN
NY52558OtherGHI/HMO