Provider Demographics
NPI:1861499824
Name:LISI, KENNETH R (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:LISI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2979 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4252
Mailing Address - Country:US
Mailing Address - Phone:203-333-8800
Mailing Address - Fax:203-384-5157
Practice Address - Street 1:2979 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4252
Practice Address - Country:US
Practice Address - Phone:203-333-8800
Practice Address - Fax:203-384-5157
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT013087207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTB38194Medicare UPIN
CT110004860Medicare UPIN