Provider Demographics
NPI:1689985160
Name:MACK, LISA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:MACK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2110 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-2313
Mailing Address - Country:US
Mailing Address - Phone:860-258-3470
Mailing Address - Fax:860-571-6800
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 1019
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-246-4029
Practice Address - Fax:860-240-7072
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2014-06-17
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Provider Licenses
StateLicense IDTaxonomies
CT0048223207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT12682481OtherCAQH