Provider Demographics
NPI:1215441423
Name:LISA ROSE DURSO, MD PLLC
Entity type:Organization
Organization Name:LISA ROSE DURSO, MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:GIACINTA
Authorized Official - Middle Name:
Authorized Official - Last Name:VITIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-828-5756
Mailing Address - Street 1:30 E 60TH ST
Mailing Address - Street 2:808
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-1008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 E 60TH ST
Practice Address - Street 2:808
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1008
Practice Address - Country:US
Practice Address - Phone:646-828-5756
Practice Address - Fax:844-742-8378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY201203OtherINTERNAL MEDICINE
1457479123OtherNPI