Provider Demographics
NPI:1770556235
Name:LISSANU, ZEWDU (MD)
Entity type:Individual
Prefix:DR
First Name:ZEWDU
Middle Name:
Last Name:LISSANU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1698 OLD LEBANON RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9662
Mailing Address - Country:US
Mailing Address - Phone:270-789-0247
Mailing Address - Fax:
Practice Address - Street 1:125 GREENBRIAR DR
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9616
Practice Address - Country:US
Practice Address - Phone:270-789-0247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36828207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64032188Medicaid
KY00524Medicare PIN
KY64032188Medicaid