Healthcare Provider Details

I. General information

NPI: 1386794576
Provider Name (Legal Business Name): LISA MARIE GUDICELLO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 NORTHERN PKWY
RIDGEWOOD NJ
07450-1721
US

IV. Provider business mailing address

440 NORTHERN PKWY
RIDGEWOOD NJ
07450-1721
US

V. Phone/Fax

Practice location:
  • Phone: 201-220-2654
  • Fax: 201-220-2654
Mailing address:
  • Phone: 201-220-2654
  • Fax: 201-220-2654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMA06926700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number318455
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: