Provider Demographics
NPI:1255322897
Name:LYSACK, JOHN TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:TIMOTHY
Last Name:LYSACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:GRB 2
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-8320
Practice Address - Fax:617-726-3077
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2240492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA478705OtherTUFTS HEALTH PLAN
MAJ29081OtherBCBS MA
MA2106621Medicaid
MA478705OtherTUFTS HEALTH PLAN
I36119Medicare UPIN