Provider Demographics
NPI:1538153101
Name:ORTENZI, LISA (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:ORTENZI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 CRESTMARK DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-2646
Mailing Address - Country:US
Mailing Address - Phone:770-941-8662
Mailing Address - Fax:770-739-6006
Practice Address - Street 1:880 CRESTMARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-2646
Practice Address - Country:US
Practice Address - Phone:770-941-8662
Practice Address - Fax:770-739-6006
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023395207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA58-1397572OtherFEDERAL TAX ID#
GA00405358AMedicaid
GAD30399Medicare UPIN
GA58-1397572OtherFEDERAL TAX ID#