Healthcare Provider Details

I. General information

NPI: 1164583613
Provider Name (Legal Business Name): VIOLETA MARINA LIZANO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 SMALLACOMBE DR
SCRANTON PA
18508-2616
US

IV. Provider business mailing address

201 SMALLACOMBE DR
SCRANTON PA
18508-2616
US

V. Phone/Fax

Practice location:
  • Phone: 570-961-0171
  • Fax: 570-207-2411
Mailing address:
  • Phone: 570-961-0171
  • Fax: 570-207-2411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD042939E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierMD042939E
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerSTATE LICENSE
# 2
Identifier0011492900005
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 3
Identifier0011492900007
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: