Provider Demographics
NPI:1003903998
Name:CORKINS, LISA BRANCATO (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:BRANCATO
Last Name:CORKINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:JEANNE
Other - Last Name:BRANCATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:500 CONGRESS ST
Mailing Address - Street 2:SUITE 1F
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169
Mailing Address - Country:US
Mailing Address - Phone:617-471-3411
Mailing Address - Fax:617-471-3584
Practice Address - Street 1:500 CONGRESS ST
Practice Address - Street 2:SUITE 1F
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-471-3411
Practice Address - Fax:617-471-3584
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23933208000000X
MA232582208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2148935Medicaid
01017BMedicare UPIN
SCGP0557Medicare ID - Type Unspecified