Provider Demographics
NPI:1780667543
Name:GUSSAK, LISA S (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:GUSSAK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:26 QUEEN ST
Mailing Address - Street 2:FAMILY PRACTICE 1
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-2473
Mailing Address - Country:US
Mailing Address - Phone:508-860-7700
Mailing Address - Fax:508-860-7929
Practice Address - Street 1:26 QUEEN ST
Practice Address - Street 2:FAMILY PRACTICE 1
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2473
Practice Address - Country:US
Practice Address - Phone:508-860-7700
Practice Address - Fax:508-860-7929
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2018-10-24
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Provider Licenses
StateLicense IDTaxonomies
MA155167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0109061Medicaid
MAGU A23275Medicare ID - Type Unspecified
MA0109061Medicaid