Healthcare Provider Details

I. General information

NPI: 1285999706
Provider Name (Legal Business Name): LISA JO VASILUTH MSED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 ROXBURY DR
COMMACK NY
11725-1324
US

IV. Provider business mailing address

31 ROXBURY DR
COMMACK NY
11725-1324
US

V. Phone/Fax

Practice location:
  • Phone: 631-827-1552
  • Fax: 631-486-4421
Mailing address:
  • Phone: 631-827-1552
  • Fax: 631-486-4421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: