Basic Information
| Provider Information | |||||||||
| NPI: | 1639425291 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PIWOSZKIN | ||||||||
| FirstName: | LISA MARIE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR BLDG B | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11115 PARKVIEW PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2606726443 | ||||||||
| FaxNumber: | 2606726459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2012 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 125061757 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 02005684A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
No ID Information.