Provider Demographics
NPI:1477588754
Name:LISI, KRISTINE M (MD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:M
Last Name:LISI
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 1:2800 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4201
Mailing Address - Country:US
Mailing Address - Phone:203-576-5440
Mailing Address - Fax:203-581-6509
Practice Address - Street 1:762 LINDLEY ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-5046
Practice Address - Country:US
Practice Address - Phone:203-576-5440
Practice Address - Fax:203-581-6509
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042871207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004187812Medicaid
CT001428714Medicaid
G46642Medicare UPIN
CTC02967Medicare ID - Type UnspecifiedGROUP
CT004187812Medicaid