Healthcare Provider Details

I. General information

NPI: 1578730990
Provider Name (Legal Business Name): LISA MARIE BARTNIKAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA MARIE STUTIUS M.D.

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 06/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6117
  • Fax:
Mailing address:
  • Phone: 617-355-6117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number225657
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number225657
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: