Healthcare Provider Details

I. General information

NPI: 1770791030
Provider Name (Legal Business Name): LISA LAVINE NAGY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2007
Last Update Date: 11/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 COURNOYER RD
VINEYARD HAVEN MA
02568-7625
US

IV. Provider business mailing address

24 COURNOYER RD
VINEYARD HAVEN MA
02568-7625
US

V. Phone/Fax

Practice location:
  • Phone: 508-693-1300
  • Fax: 508-639-1305
Mailing address:
  • Phone: 508-693-1300
  • Fax: 508-693-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number72590
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number72590
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier110086513A
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: