1003809450 NPI number — LISA A TOMSAK DO

Table of content: LISA A TOMSAK DO (NPI 1003809450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003809450 NPI number — LISA A TOMSAK DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TOMSAK
Provider First Name:
LISA
Provider Middle Name:
A
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:
COSTARIS
Provider Other First Name:
LISA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003809450
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4036 ARTESA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOYNTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33436-2628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-466-5757
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1590 S CONGRESS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33406-5957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-466-5757
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2005

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: 207RA0401X , with the licence number:  OS007618L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RA0401X , with the licence number: 036162516 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2083A0300X , with the licence number: 02005078A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2083A0300X , with the licence number: OS14219 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2083A0300X , with the licence number: 007179 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2083A0300X , with the licence number: OP60707874 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RA0401X , with the licence number: 25MB11582500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RA0401X , with the licence number: DR.0068878 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RA0401X , with the licence number: DO3188 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RA0401X , with the licence number: 18636 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0013931090006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".