Provider Demographics
NPI:1699705863
Name:BANCHIK, LISA INGRID (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:INGRID
Last Name:BANCHIK
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 1:5458 TOWN CENTER RD
Mailing Address - Street 2:SUITE #22
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-1089
Mailing Address - Country:US
Mailing Address - Phone:561-392-2950
Mailing Address - Fax:561-391-2970
Practice Address - Street 1:5458 TOWN CENTER RD
Practice Address - Street 2:SUITE #22
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-1089
Practice Address - Country:US
Practice Address - Phone:561-392-2950
Practice Address - Fax:561-391-2970
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00552182084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE34045Medicare UPIN
FL09342XMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER