Provider Demographics
NPI:1952792368
Name:LIZARDO, THERESE (MD)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:LIZARDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THERESE
Other - Middle Name:LORRAINE
Other - Last Name:LIZARDO-ESCANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:165 PARLIN LN
Mailing Address - Street 2:
Mailing Address - City:WATCHUNG
Mailing Address - State:NJ
Mailing Address - Zip Code:07069-5400
Mailing Address - Country:US
Mailing Address - Phone:202-302-4765
Mailing Address - Fax:
Practice Address - Street 1:165 PARLIN LN
Practice Address - Street 2:
Practice Address - City:WATCHUNG
Practice Address - State:NJ
Practice Address - Zip Code:07069-5400
Practice Address - Country:US
Practice Address - Phone:908-757-2149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-08
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA09642100207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program