Basic Information
| Provider Information | |||||||||
| NPI: | 1881677763 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IMUNDO | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | FLORENCE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 161 FORT WASHINGTON AVE FL 2 | ||||||||
| Address2: | COLUMBIA UNIVERSITY | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123047250 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 161 FORT WASHINGTON AVE FL 2 | ||||||||
| Address2: | COLUMBIA UNIVERSITY DEPARTMENT OF PEDIATRICS | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123047250 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 11/24/2015 | ||||||||
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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 | 2080P0216X | 180212-1 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 01605063 | 05 | NY | MEDICAID |