Healthcare Provider Details

I. General information

NPI: 1215953229
Provider Name (Legal Business Name): LISA MARIE ROTELLI D. O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 DECKER DR STE 100
JOHNSTOWN NY
12095-2157
US

IV. Provider business mailing address

99 E STATE ST
GLOVERSVILLE NY
12078-1203
US

V. Phone/Fax

Practice location:
  • Phone: 518-762-6731
  • Fax: 518-762-7135
Mailing address:
  • Phone: 518-762-6731
  • Fax: 518-762-7135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDO-901
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number229169
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number229169
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: