Provider Demographics
NPI:1386794576
Name:GUDICELLO, LISA MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:GUDICELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:440 NORTHERN PKWY
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-1721
Mailing Address - Country:US
Mailing Address - Phone:201-220-2654
Mailing Address - Fax:201-220-2654
Practice Address - Street 1:440 NORTHERN PKWY
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-1721
Practice Address - Country:US
Practice Address - Phone:201-220-2654
Practice Address - Fax:201-220-2654
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA06926700207W00000X
NY318455207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG87229Medicare UPIN
NJ027685UPLMedicare PIN