Healthcare Provider Details

I. General information

NPI: 1396242590
Provider Name (Legal Business Name): LISA SERVENTI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 02/24/2023
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 CRANBURY RD STE LL90
EAST BRUNSWICK NJ
08816-4098
US

IV. Provider business mailing address

234 E 149TH ST RM 518
BRONX NY
10451-5504
US

V. Phone/Fax

Practice location:
  • Phone: 732-257-0081
  • Fax: 732-613-4845
Mailing address:
  • Phone: 718-579-5030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MA11552100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: