Provider Demographics
NPI:1346800810
Name:MEMIA, AGLISA (MD)
Entity Type:Individual
Prefix:
First Name:AGLISA
Middle Name:
Last Name:MEMIA
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 1:585 LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-3298
Mailing Address - Country:US
Mailing Address - Phone:781-979-3861
Mailing Address - Fax:781-979-3860
Practice Address - Street 1:585 LEBANON ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3298
Practice Address - Country:US
Practice Address - Phone:781-979-3861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA292146207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program