MEDICARE: DR. LISA PEDEVILLANO DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician	OS023186	PA

General Provider Information

NPI Number	:	1720433535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA PEDEVILLANO DO

Provider Business Mailing Address
First Line	:	1430 W SHERMAN AVE
Second Line	:
City	:	VINELAND
State	:	NJ
Zip	:	08360-6927
Country	:	US
Telephone Number	:	845-797-5195
Fax Number	:

Provider Business Practice Location Address
First Line	:	9501 ROOSEVELT BLVD STE 312
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19114-1028
Country	:	US
Telephone Number	:	215-331-7001
Fax Number	:	215-331-7004

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2016
Last Update Date	:	10/31/2023

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Directions to “ DR. LISA PEDEVILLANO DO” Practice Location

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