Provider Demographics
NPI:1275845729
Name:LISIK, CHANTAL MULAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANTAL
Middle Name:MULAN
Last Name:LISIK
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 1:67 WALNUT AVE STE 402
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1687
Mailing Address - Country:US
Mailing Address - Phone:732-499-9110
Mailing Address - Fax:855-822-3223
Practice Address - Street 1:67 WALNUT AVE STE 402
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066
Practice Address - Country:US
Practice Address - Phone:908-868-6669
Practice Address - Fax:855-822-3223
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282N00000X
NJ25MA08971700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty