Provider Demographics
NPI:1912960436
Name:KASSENOFF, LISA ADRIAN (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ADRIAN
Last Name:KASSENOFF
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 RTE 9 S
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-3625
Mailing Address - Country:US
Mailing Address - Phone:609-756-0000
Mailing Address - Fax:609-488-1613
Practice Address - Street 1:138 RTE 9 S
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-3625
Practice Address - Country:US
Practice Address - Phone:609-756-0000
Practice Address - Fax:609-488-1613
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB07878100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJI29952Medicare UPIN