Provider Demographics
NPI:1396742797
Name:MANSUETO, LISA ANN (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:MANSUETO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3200 S COUNTRY CLUB WAY
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-4054
Mailing Address - Country:US
Mailing Address - Phone:480-839-0206
Mailing Address - Fax:480-831-6735
Practice Address - Street 1:3200 S COUNTRY CLUB WAY
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-4054
Practice Address - Country:US
Practice Address - Phone:480-839-0206
Practice Address - Fax:480-831-6735
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2016-05-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ23840207W00000X, 207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3743063OtherCIGNA
AZ455354Medicaid
AZ3743063OtherCIGNA
26854Medicare ID - Type Unspecified