Provider Demographics
NPI:1720433535
Name:PEDEVILLANO, LISA (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:PEDEVILLANO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1430 W SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-6927
Mailing Address - Country:US
Mailing Address - Phone:845-797-5195
Mailing Address - Fax:
Practice Address - Street 1:9501 ROOSEVELT BLVD STE 312
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1028
Practice Address - Country:US
Practice Address - Phone:215-331-7001
Practice Address - Fax:215-331-7004
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS0231862086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery