Healthcare Provider Details

I. General information

NPI: 1639173123
Provider Name (Legal Business Name): BOAZ J LISSAUER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1036 PARK AVE SUITE 1C
NEW YORK NY
10028-0971
US

IV. Provider business mailing address

1036 PARK AVE SUITE 1C
NEW YORK NY
10028-0971
US

V. Phone/Fax

Practice location:
  • Phone: 212-717-2150
  • Fax: 212-717-2154
Mailing address:
  • Phone: 212-717-2150
  • Fax: 212-717-2154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number208452
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number25MA07699200
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number25MA07699200
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number208452
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: