Provider Demographics
NPI:1609988823
Name:PROCK, LISA (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:PROCK
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:HOEFT
Other - Last Name:ALBERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, MPH
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-755-0561
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-4125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA81196208000000X, 2080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3145550Medicaid
MA3145550Medicaid
AL A21034Medicare ID - Type Unspecified