Healthcare Provider Details

I. General information

NPI: 1134448269
Provider Name (Legal Business Name): CARISSA A WEBSTER-LAKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2010
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 ALBANY AVE # 1056
WEST HARTFORD CT
06117-2335
US

IV. Provider business mailing address

2550 ALBANY AVE # 1056
WEST HARTFORD CT
06117-2335
US

V. Phone/Fax

Practice location:
  • Phone: 617-869-0135
  • Fax:
Mailing address:
  • Phone:
  • Fax: 901-271-0155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number54698
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number54698
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number0101279557
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number59921
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: