Provider Demographics
NPI:1235129222
Name:LISA ANTONELLI MD
Entity Type:Organization
Organization Name:LISA ANTONELLI MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-472-6953
Mailing Address - Street 1:460 TOTTEN POND RD
Mailing Address - Street 2:C O MZI
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1906
Mailing Address - Country:US
Mailing Address - Phone:781-890-9933
Mailing Address - Fax:781-890-9950
Practice Address - Street 1:500 CONGRESS ST
Practice Address - Street 2:STE 2F
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-0908
Practice Address - Country:US
Practice Address - Phone:617-472-6953
Practice Address - Fax:617-773-2193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ09499OtherBCBS
MA3060284Medicaid
MA755370OtherTUFTS
MAJ09499OtherBCBS