Provider Demographics
NPI:1073593299
Name:THAYER, LISA A (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:THAYER
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 1:485 ARSENAL ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-5091
Mailing Address - Country:US
Mailing Address - Phone:617-972-5570
Mailing Address - Fax:617-972-5593
Practice Address - Street 1:485 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-5091
Practice Address - Country:US
Practice Address - Phone:617-972-5570
Practice Address - Fax:617-972-5593
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA155172208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0015185OtherNEIGHBORHOOD HEALTH
MA3189732Medicaid
MAJ19137OtherBLUE CROSS
MAPP820OtherHARVARD PILGRIM
MA155172OtherTUFTS
MA155172OtherTUFTS
MAG84311Medicare UPIN