Provider Demographics
NPI:1275646085
Name:FILLMORE, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FILLMORE
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 1:60 WASHINGTON AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518
Mailing Address - Country:US
Mailing Address - Phone:203-281-2890
Mailing Address - Fax:203-281-2896
Practice Address - Street 1:60 WASHINGTON AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518
Practice Address - Country:US
Practice Address - Phone:203-281-2890
Practice Address - Fax:203-281-2896
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0379832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
I11149Medicare UPIN