Healthcare Provider Details

I. General information

NPI: 1912960436
Provider Name (Legal Business Name): LISA ADRIAN KASSENOFF D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 RTE 9 S
FORKED RIVER NJ
08731-3625
US

IV. Provider business mailing address

138 RTE 9 S
FORKED RIVER NJ
08731-3625
US

V. Phone/Fax

Practice location:
  • Phone: 609-756-0000
  • Fax: 609-488-1613
Mailing address:
  • Phone: 609-756-0000
  • Fax: 609-488-1613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMB07878100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: