Provider Demographics
NPI:1649220179
Name:JOHNSON, LISE CAROLYN (MD)
Entity Type:Individual
Prefix:
First Name:LISE
Middle Name:CAROLYN
Last Name:JOHNSON
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 1:75 FRANCIS STREET
Mailing Address - Street 2:BRIGHAM AND WOMENS HOSPITAL DEPT OF NEWBORN MEDICINE
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-732-5952
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS STREET
Practice Address - Street 2:BRIGHAM AND WOMENS HOSPITAL DEPT OF NEWBORN MEDICINE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-732-5952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA74261208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics