1043219215 NPI number — DR. LISA A DEBERNARDI DPM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043219215 NPI number — DR. LISA A DEBERNARDI DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEBERNARDI
Provider First Name:
LISA
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1043219215
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5108 HAMPTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63109-3113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-821-3668
Provider Business Mailing Address Fax Number:
888-966-0079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5108 HAMPTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63109-3113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-821-3668
Provider Business Practice Location Address Fax Number:
888-966-0079
Provider Enumeration Date:
07/19/2005

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: 213E00000X , with the licence number:  016004789 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213EP1101X , with the licence number: 2008030512 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 016004789 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1043219215 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1622982 . This is a "BLUE CROSS / BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 480014516 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P01302982 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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