Basic Information
| Provider Information | |||||||||
| NPI: | 1124218540 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERR | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 WILLIAMSON ST | ||||||||
| Address2: | STE 104 | ||||||||
| City: | ELIZABETH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 072023671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567969200 | ||||||||
| FaxNumber: | 8567969397 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 WILLIAMSON ST | ||||||||
| Address2: | STE 104 | ||||||||
| City: | ELIZABETH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 072023671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9089945480 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2007 | ||||||||
| LastUpdateDate: | 03/23/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 25MB08941100 | NJ | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0270661 | 05 | NJ | MEDICAID |