Provider Demographics
NPI:1669421053
Name:BARDACK, LISA R (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:BARDACK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:110 S BEDFORD RD
Mailing Address - Street 2:CARE MOUNT MEDICAL PC
Mailing Address - City:MOUNT KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549-3446
Mailing Address - Country:US
Mailing Address - Phone:914-241-1050
Mailing Address - Fax:914-242-1516
Practice Address - Street 1:90 S BEDFORD RD
Practice Address - Street 2:CARE MOUNT MEDICAL PC
Practice Address - City:MOUNT KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549-3412
Practice Address - Country:US
Practice Address - Phone:914-241-1050
Practice Address - Fax:914-242-1516
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2016-11-11
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Provider Licenses
StateLicense IDTaxonomies
NY187980207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01435758Medicaid
NY0667910001OtherDME
NY110153364OtherMEDICARE RAILROAD
NY01435758Medicaid
NYF56403Medicare UPIN
NY0667910001OtherDME