Provider Demographics
NPI:1821300807
Name:LICARE, LISA A (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:LICARE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-5544
Mailing Address - Country:US
Mailing Address - Phone:860-444-3366
Mailing Address - Fax:
Practice Address - Street 1:194 HOWARD ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-5544
Practice Address - Country:US
Practice Address - Phone:860-444-3366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT54140207V00000X
RIDO00810207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology