Provider Demographics
NPI:1982762381
Name:LISA C. DIMEDIO, D.O., P. C.
Entity type:Organization
Organization Name:LISA C. DIMEDIO, D.O., P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMEDIO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-227-8611
Mailing Address - Street 1:1652 COOPER ST
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-3768
Mailing Address - Country:US
Mailing Address - Phone:856-227-8611
Mailing Address - Fax:856-227-5716
Practice Address - Street 1:1652 COOPER ST
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-3768
Practice Address - Country:US
Practice Address - Phone:856-227-8611
Practice Address - Fax:856-227-5716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06370800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty