MEDICARE: LISA VIDES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1386572923
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA VIDES

Provider Business Mailing Address
First Line	:	2957 ROXBURY RD
Second Line	:
City	:	OCEANSIDE
State	:	NY
Zip	:	11572-3216
Country	:	US
Telephone Number	:	516-388-1233
Fax Number	:

Provider Business Practice Location Address
First Line	:	2957 ROXBURY RD
Second Line	:
City	:	OCEANSIDE
State	:	NY
Zip	:	11572-3216
Country	:	US
Telephone Number	:	516-993-1696
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2026
Last Update Date	:	05/13/2026

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Directions to “ LISA VIDES ” Practice Location

Language	Start Address	Practice Location

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