1720077019 NPI number — LISSA M JEAN-PIERRE MD

Table of content: LISSA M JEAN-PIERRE MD (NPI 1720077019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720077019 NPI number — LISSA M JEAN-PIERRE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JEAN-PIERRE
Provider First Name:
LISSA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720077019
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10510 NW 10TH CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANTATION
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33322-6537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-648-8999
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13220 BELCHER RD S UNIT 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33773-1677
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-351-4894
Provider Business Practice Location Address Fax Number:
727-351-4897
Provider Enumeration Date:
10/19/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  ME85417 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 260573200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 108559000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".