Healthcare Provider Details

I. General information

NPI: 1316973217
Provider Name (Legal Business Name): JEFFREY R LISSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 N. WILMOT #101
TUCSON AZ
85711
US

IV. Provider business mailing address

2701 E ELVIRA RD
TUCSON AZ
85706-7124
US

V. Phone/Fax

Practice location:
  • Phone: 520-874-7400
  • Fax: 520-874-3425
Mailing address:
  • Phone: 520-874-7400
  • Fax: 520-874-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number28777
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: