1275975161 NPI number — LISA DIANE IUCCI DO

Table of content: LISA DIANE IUCCI DO (NPI 1275975161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275975161 NPI number — LISA DIANE IUCCI DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IUCCI
Provider First Name:
LISA
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARASYMCZUK
Provider Other First Name:
LISA
Provider Other Middle Name:
DIANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275975161
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 SCHULZ DR STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RED BANK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07701-6745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
327-426-3420
Provider Business Mailing Address Fax Number:
732-747-2606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4096 ENGLISH CREEK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EGG HARBOR TOWNSHIP
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08234-5746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-204-5357
Provider Business Practice Location Address Fax Number:
609-272-7755
Provider Enumeration Date:
07/22/2013

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: 208600000X , with the licence number:  25MB10400100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0647276 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".