Healthcare Provider Details

I. General information

NPI: 1437147667
Provider Name (Legal Business Name): LISA J VUKALCIC M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 CAMBRIDGE STREET
BOSTON MA
02135-2907
US

IV. Provider business mailing address

690 CANTON STREET SUITE 325
WESTWOOD MA
02090-2329
US

V. Phone/Fax

Practice location:
  • Phone: 617-789-2782
  • Fax: 907-258-2147
Mailing address:
  • Phone: 781-407-7713
  • Fax: 781-407-0998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number3105
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number246553
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: