Provider Demographics
NPI:1659319200
Name:LIFSON, BARRY J (MD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:J
Last Name:LIFSON
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:PO BOX 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:171 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-5122
Practice Address - Country:US
Practice Address - Phone:843-792-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21082208800000X
SC83343208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3003509000Medicaid
WV340020612OtherRAILROAD MEDICARE
WV000272087OtherBLUE CROSS BLUE SHIELD
WV005185537OtherAETNA
OH2393806Medicaid
WV4098521Medicare ID - Type Unspecified
WV3003509000Medicaid
WV000272087OtherBLUE CROSS BLUE SHIELD