Healthcare Provider Details

I. General information

NPI: 1811943897
Provider Name (Legal Business Name): LISA KAUSHAL TANK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE DIVISION OF GERIATRICS
HACKENSACK NJ
07601-1914
US

IV. Provider business mailing address

30 PROSPECT AVE DIVISION OF GERIATRICS
HACKENSACK NJ
07601-1914
US

V. Phone/Fax

Practice location:
  • Phone: 201-678-2994
  • Fax: 201-678-2976
Mailing address:
  • Phone: 201-678-2994
  • Fax: 201-678-2976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberMA073309
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier8850801
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: