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General NPI Number Information
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NPI Number | 1033188669
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Entity Type | Individual
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Provider Name | LISA REEVES MAHONEY MD
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Gender | Female
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Dates
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Enumeration Date | 03/16/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 565 ROUTE 25A SUITE 4
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City | MILLER PLACE
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State | NY
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Zip | 11764-2663
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Country | US
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Telephone | 631-821-9200
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Fax | 631-821-3266
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Provider Business Mailing Address
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Address Line | 565 ROUTE 25A SUITE 4
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City | MILLER PLACE
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State | NY
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Zip | 11764-2663
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Country | US
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Telephone | 631-821-9200
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Fax | 631-821-3266
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 124569
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License Number State | NY
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