Healthcare Provider Details

I. General information

NPI: 1851327001
Provider Name (Legal Business Name): LIEZL G. IRISARI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11107 RACETRACK RD
BERLIN MD
21811-3279
US

IV. Provider business mailing address

10026 OLD OCEAN CITY BLVD BUILDING #1
BERLIN MD
21811-1288
US

V. Phone/Fax

Practice location:
  • Phone: 410-208-9761
  • Fax: 410-208-9764
Mailing address:
  • Phone: 410-641-9450
  • Fax: 410-641-9515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number230999
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number230999
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: