Provider Demographics
NPI:1831133289
Name:VILISSOVA, NATALIE V (MD)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:V
Last Name:VILISSOVA
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 1:133 ORNAC
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-4159
Mailing Address - Country:US
Mailing Address - Phone:978-287-3167
Mailing Address - Fax:978-287-3391
Practice Address - Street 1:133 ORNAC
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-4159
Practice Address - Country:US
Practice Address - Phone:978-287-3167
Practice Address - Fax:978-287-3391
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213773207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA28347OtherHARVARD PILGRIM HEALTHCAR
3767953OtherAETNA
MAJ28496OtherBCBS
467891OtherTUFTS HEALTH CARE
MA93039OtherFALLON
AA28347OtherHARVARD PILGRIM HEALTHCAR
I25402Medicare UPIN