Provider Demographics
NPI:1134448269
Name:WEBSTER-LAKE, CARISSA A (MD)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:A
Last Name:WEBSTER-LAKE
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 1:2550 ALBANY AVE # 1056
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-2335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-271-0155
Practice Address - Street 1:2550 ALBANY AVE # 1056
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-2335
Practice Address - Country:US
Practice Address - Phone:617-869-0135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT54698208600000X, 2086S0129X
VA01012795572086S0129X
TN599212086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery