Provider Demographics
NPI:1104877737
Name:DIRENZO, LISA M (DO)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:DIRENZO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 LIMESTONE RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-5553
Mailing Address - Country:US
Mailing Address - Phone:302-995-1860
Mailing Address - Fax:302-995-5421
Practice Address - Street 1:2006 LIMESTONE RD
Practice Address - Street 2:SUITE 5
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-5553
Practice Address - Country:US
Practice Address - Phone:302-995-1860
Practice Address - Fax:302-995-5421
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS 007958 L207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G17353Medicare UPIN
786551Medicare ID - Type Unspecified