Provider Demographics
NPI:1689674814
Name:LISCIANDRO, KELLY ANNE (DO)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANNE
Last Name:LISCIANDRO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:6720 PITTSFORD PALMYRA ROAD
Mailing Address - Street 2:STE 15
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450
Mailing Address - Country:US
Mailing Address - Phone:585-364-0025
Mailing Address - Fax:585-364-0024
Practice Address - Street 1:6720 PITTSFORD PALMYRA ROAD
Practice Address - Street 2:STE 15
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450
Practice Address - Country:US
Practice Address - Phone:585-364-0025
Practice Address - Fax:585-364-0024
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY228369-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY115965BJOtherPREFERRED CARE
NY7441491OtherAETNA
NY02423485Medicaid
NYP010228369OtherBLUE CHOICE
NYH81262Medicare UPIN
NYDD5136Medicare ID - Type Unspecified