Provider Demographics
NPI:1679793269
Name:FAZZOLARI, LISA ROSEMARY (DO)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ROSEMARY
Last Name:FAZZOLARI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5674 STONERIDGE DR
Mailing Address - Street 2:SUITE 116
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-8500
Mailing Address - Country:US
Mailing Address - Phone:925-520-0005
Mailing Address - Fax:
Practice Address - Street 1:5674 STONERIDGE DR
Practice Address - Street 2:SUITE 116
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-8500
Practice Address - Country:US
Practice Address - Phone:925-520-0005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A83712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry