Provider Demographics
NPI:1740449909
Name:THANNIKARY, LISA J (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:THANNIKARY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 GATEWICK PL
Mailing Address - Street 2:
Mailing Address - City:KESWICK
Mailing Address - State:VA
Mailing Address - Zip Code:22947-9119
Mailing Address - Country:US
Mailing Address - Phone:434-202-2980
Mailing Address - Fax:
Practice Address - Street 1:1215 LEE ST
Practice Address - Street 2:DEPARTMENT OF ANESTHESIOLOGY
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0710
Practice Address - Country:US
Practice Address - Phone:434-924-9508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87621207L00000X
VA0101248535207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267044500Medicaid
FL78781YMedicare PIN
FL267044500Medicaid