Healthcare Provider Details

I. General information

NPI: 1881162402
Provider Name (Legal Business Name): LISA JEANNE SANDERS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA JEANNE ISTORICO MD

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 E 7TH AVE STE 104
TAMPA FL
33605-3606
US

IV. Provider business mailing address

PO BOX 917770
ORLANDO FL
32891-0001
US

V. Phone/Fax

Practice location:
  • Phone: 813-396-9021
  • Fax:
Mailing address:
  • Phone: 813-974-2201
  • Fax: 813-974-2812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number53030
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License NumberME53030
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: