Provider Demographics
NPI:1811968316
Name:LISA, CHARLES (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:LISA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2309 E EVESHAM RD
Mailing Address - Street 2:SUITE #202
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-1559
Mailing Address - Country:US
Mailing Address - Phone:856-489-1900
Mailing Address - Fax:856-489-7945
Practice Address - Street 1:2309 E EVESHAM RD
Practice Address - Street 2:SUITE #202
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-1559
Practice Address - Country:US
Practice Address - Phone:856-489-1900
Practice Address - Fax:856-489-7945
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA02872400207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1371401Medicaid
C53894Medicare UPIN
NJ420791AFEMedicare PIN