Provider Demographics
NPI:1336182260
Name:LISAK, JAMES CHESTER (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:CHESTER
Last Name:LISAK
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:PO BOX 79141
Mailing Address - Street 2:
Mailing Address - City:NORTH DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-0991
Mailing Address - Country:US
Mailing Address - Phone:774-202-6240
Mailing Address - Fax:774-202-5179
Practice Address - Street 1:360 FAUNCE CORNER RD
Practice Address - Street 2:# 3
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-1257
Practice Address - Country:US
Practice Address - Phone:774-202-6240
Practice Address - Fax:774-202-5179
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52025207R00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3017117Medicaid
MAJ06006OtherBLUE SHIELD MASSACHUSETTS
MA3017117Medicaid
MA3017117Medicaid