Provider Demographics
NPI:1235336140
Name:TILLUCKDHARRY, LISA (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:TILLUCKDHARRY
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 1:248 PLEASANT ST
Mailing Address - Street 2:SUITE G100
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-2588
Mailing Address - Country:US
Mailing Address - Phone:603-224-9661
Mailing Address - Fax:603-228-7051
Practice Address - Street 1:248 PLEASANT ST
Practice Address - Street 2:SUITE G100
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-2588
Practice Address - Country:US
Practice Address - Phone:603-224-9661
Practice Address - Fax:603-228-7051
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH14363207RC0200X, 207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1016776Medicaid
NH30208990Medicaid
NH001282101Medicare PIN