Provider Demographics
NPI:1013942531
Name:LISAK, JOAN WANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:WANDA
Last Name:LISAK
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:PO BOX 2041
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01101-2041
Mailing Address - Country:US
Mailing Address - Phone:413-781-2200
Mailing Address - Fax:413-781-2202
Practice Address - Street 1:780 CHESTNUT ST
Practice Address - Street 2:SUITE 20
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1610
Practice Address - Country:US
Practice Address - Phone:413-781-2200
Practice Address - Fax:413-781-2202
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57480207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3089428Medicaid
MAF18684Medicare UPIN
MAJ12100Medicare ID - Type Unspecified