Provider Demographics
NPI:1891920625
Name:TISO, STEPHANIE TERESA (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:TERESA
Last Name:TISO
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 1:120 PARK LANE RD
Mailing Address - Street 2:SUITE A-101
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-2444
Mailing Address - Country:US
Mailing Address - Phone:860-355-8190
Mailing Address - Fax:860-355-3856
Practice Address - Street 1:120 PARK LANE RD
Practice Address - Street 2:SUITE A-101
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-2444
Practice Address - Country:US
Practice Address - Phone:860-355-8190
Practice Address - Fax:860-355-3856
Is Sole Proprietor?:No
Enumeration Date:2009-05-22
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT051071208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008041366Medicaid