Provider Demographics
NPI:1215953229
Name:ROTELLI, LISA MARIE (D O)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:ROTELLI
Suffix:
Gender:F
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-1203
Mailing Address - Country:US
Mailing Address - Phone:518-762-6731
Mailing Address - Fax:518-762-7135
Practice Address - Street 1:110 DECKER DR STE 100
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:NY
Practice Address - Zip Code:12095-2157
Practice Address - Country:US
Practice Address - Phone:518-762-6731
Practice Address - Fax:518-762-7135
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO-901208000000X
NY229169208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-47615OtherBCBS OF AL
AL009939008Medicaid
AL009939007Medicaid
AL009939008Medicaid