Provider Demographics
NPI:1669729828
Name:LISOTTO, MARIA JOSE (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:JOSE
Last Name:LISOTTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:JULIOS COSTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:30 N GOULD ST # 42229
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-6317
Mailing Address - Country:US
Mailing Address - Phone:617-651-2111
Mailing Address - Fax:815-205-4478
Practice Address - Street 1:1 BROOKLINE PL STE 502
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7277
Practice Address - Country:US
Practice Address - Phone:617-651-2111
Practice Address - Fax:815-205-4478
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2024-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4556552084P0800X
MAMD2665172084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry