Provider Demographics
NPI:1346264124
Name:KOWALSKI, LISE S (MD)
Entity Type:Individual
Prefix:DR
First Name:LISE
Middle Name:S
Last Name:KOWALSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:LISE
Other - Middle Name:S
Other - Last Name:THIBODEAU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:94 WEST HILL RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05682
Mailing Address - Country:US
Mailing Address - Phone:802-225-7047
Mailing Address - Fax:
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:SUITE 3-1
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-225-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT420008605207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01206986Medicaid
VTOVN0444Medicaid
NY01206986Medicaid
VTVN0444Medicare PIN