Provider Demographics
NPI:1801106059
Name:LYSSE, MARIO (MD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:LYSSE
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 1:280 CHESTNUT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1001
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:95 SARGENT STREET
Practice Address - Street 2:ROUTE 9
Practice Address - City:BELCHERTOWN
Practice Address - State:MA
Practice Address - Zip Code:01007-9881
Practice Address - Country:US
Practice Address - Phone:413-323-7212
Practice Address - Fax:413-967-2524
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA246152207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine