Healthcare Provider Details

I. General information

NPI: 1720022866
Provider Name (Legal Business Name): LISA A. LESKO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 WATER ST
BLUE HILL ME
04614-5231
US

IV. Provider business mailing address

57 WATER ST
BLUE HILL ME
04614-5231
US

V. Phone/Fax

Practice location:
  • Phone: 207-374-2311
  • Fax: 207-374-3991
Mailing address:
  • Phone: 207-374-2311
  • Fax: 207-374-3991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD14288
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: