Provider Demographics
NPI:1639173123
Name:LISSAUER, BOAZ J (MD)
Entity Type:Individual
Prefix:DR
First Name:BOAZ
Middle Name:J
Last Name:LISSAUER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 PARK AVE
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0971
Mailing Address - Country:US
Mailing Address - Phone:212-717-2150
Mailing Address - Fax:212-717-2154
Practice Address - Street 1:1036 PARK AVE
Practice Address - Street 2:SUITE 1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0971
Practice Address - Country:US
Practice Address - Phone:212-717-2150
Practice Address - Fax:212-717-2154
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208452207W00000X, 2086S0122X
NJ25MA07699200207W00000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBL0482B310OtherFEDERAL BLUE CROSS BLUE S
7554155OtherAETNA
NYBL0482B310OtherBLUE CROSS BLUE SHIELD
P2647045OtherOXFORD
NY0498250OtherGHI
NY1000035875OtherAFFNITY HEALTH PLAN
NY208452OtherHIP
NY271252BOtherDIVISION 1181 MAGNACARE
H38324Medicare UPIN
NY377A91Medicare ID - Type Unspecified