Healthcare Provider Details

I. General information

NPI: 1538564323
Provider Name (Legal Business Name): LISA CHANG SCHLUSSEL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA CHANG D.O.

II. Dates (important events)

Enumeration Date: 10/23/2014
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GATEWAY CTR STE 2600
NEWARK NJ
07102-5323
US

IV. Provider business mailing address

109 STATE ST STE 5
BOSTON MA
02109-2906
US

V. Phone/Fax

Practice location:
  • Phone: 617-505-1520
  • Fax: 617-928-8401
Mailing address:
  • Phone: 617-505-1520
  • Fax: 617-928-8401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number64504
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB13131200
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number340935
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: