Provider Demographics
NPI:1710925367
Name:CODISPOTI, VICTORIA LISA (MD)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LISA
Last Name:CODISPOTI
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 1:4232 CARTTER RD
Mailing Address - Street 2:
Mailing Address - City:KELL
Mailing Address - State:IL
Mailing Address - Zip Code:62853-1148
Mailing Address - Country:US
Mailing Address - Phone:618-292-3437
Mailing Address - Fax:618-242-8240
Practice Address - Street 1:4232 CARTTER RD
Practice Address - Street 2:
Practice Address - City:KELL
Practice Address - State:IL
Practice Address - Zip Code:62853-1148
Practice Address - Country:US
Practice Address - Phone:618-292-3437
Practice Address - Fax:618-242-8240
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361081092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036108109Medicaid
ILK08396Medicare ID - Type UnspecifiedMEMBER NUMBER