Basic Information
| Provider Information | |||||||||
| NPI: | 1265527410 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POMPEO | ||||||||
| FirstName: | LISA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 BERGEN ST | ||||||||
| Address2: | ADMC 12 1205 | ||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071073000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739720037 | ||||||||
| FaxNumber: | 9739729355 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 BERGEN ST | ||||||||
| Address2: | ACC LEVEL C | ||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071032425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739722700 | ||||||||
| FaxNumber: | 9739722739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 25MA06314800 | NJ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 7648600 | 05 | NJ | MEDICAID |