Provider Demographics
NPI:1649255167
Name:CANTOR-JACOBSON, LISA MARIE (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:CANTOR-JACOBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:CANTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3000 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:OH
Mailing Address - Zip Code:45103-1921
Mailing Address - Country:US
Mailing Address - Phone:513-732-8629
Mailing Address - Fax:513-732-8626
Practice Address - Street 1:3000 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:OH
Practice Address - Zip Code:45103-1921
Practice Address - Country:US
Practice Address - Phone:513-732-8629
Practice Address - Fax:513-732-8626
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0709772084P0800X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2183971Medicaid
OHCA4131203Medicare PIN
H11806Medicare UPIN
OHCA4131202Medicare PIN
CA4012761Medicare ID - Type Unspecified