Provider Demographics
NPI:1851326151
Name:LI, LISA (DO)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 ROUTE 10 E
Mailing Address - Street 2:STE 101
Mailing Address - City:SUCCASUNNA
Mailing Address - State:NJ
Mailing Address - Zip Code:07876-1300
Mailing Address - Country:US
Mailing Address - Phone:973-989-3085
Mailing Address - Fax:973-989-3106
Practice Address - Street 1:225 ROUTE 10 E
Practice Address - Street 2:SUITE 201
Practice Address - City:SUCCASUNNA
Practice Address - State:NJ
Practice Address - Zip Code:07876-1300
Practice Address - Country:US
Practice Address - Phone:973-584-1405
Practice Address - Fax:973-584-6889
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07630500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0131482Medicaid
NJ0131482Medicaid
076976Medicare ID - Type Unspecified