Provider Demographics
NPI:1770534844
Name:PLANETA, LISA A (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:PLANETA
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 1:444 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:CHICOPEE
Mailing Address - State:MA
Mailing Address - Zip Code:01020-1969
Mailing Address - Country:US
Mailing Address - Phone:413-594-3111
Mailing Address - Fax:413-789-8048
Practice Address - Street 1:444 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01020-1969
Practice Address - Country:US
Practice Address - Phone:413-594-3111
Practice Address - Fax:413-789-8048
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-13
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA79242208600000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3189597Medicaid
MA3189597Medicaid
MAA28961Medicare ID - Type Unspecified