Provider Demographics
NPI:1851327001
Name:IRISARI, LIEZL G (MD)
Entity Type:Individual
Prefix:
First Name:LIEZL
Middle Name:G
Last Name:IRISARI
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 1:10026 OLD OCEAN CITY BLVD
Mailing Address - Street 2:BUILDING #1
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1288
Mailing Address - Country:US
Mailing Address - Phone:410-641-9450
Mailing Address - Fax:410-641-9515
Practice Address - Street 1:11107 RACETRACK RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-3279
Practice Address - Country:US
Practice Address - Phone:410-208-9761
Practice Address - Fax:410-208-9764
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2309992088F0040X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No2088F0040XAllopathic & Osteopathic PhysiciansUrologyFemale Pelvic Medicine and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110076111AMedicaid
MA000226601Medicare PIN