Healthcare Provider Details

I. General information

NPI: 1942461942
Provider Name (Legal Business Name): LISA MARIE GEHEB VOPAT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 06/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 LONGWOOD AVE
BOSTON MA
02115-5728
US

IV. Provider business mailing address

319 LONGWOOD AVE
BOSTON MA
02115-5728
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-8597
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number250767
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: