=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689611857
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENIS N LUSIGNAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2006
-----------------------------------------------------
Last Update Date | 09/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 PARK ST SUITE 202
-----------------------------------------------------
City | GLENS FALLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12801-4449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-761-2347
-----------------------------------------------------
Fax | 518-793-6658
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 787 102 PARK ST., SUITE 202
-----------------------------------------------------
City | GLENS FALLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12801-4449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-761-2347
-----------------------------------------------------
Fax | 518-793-6658
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 104380
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------