MEDICARE: CARISSA A WEBSTER-LAKE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	54698	CT
2	2086S0129X	Vascular Surgery Physician	54698	CT
3	2086S0129X	Vascular Surgery Physician	0101279557	VA
4	2086S0129X	Vascular Surgery Physician	59921	TN

General Provider Information

NPI Number	:	1134448269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARISSA A WEBSTER-LAKE MD

Provider Business Mailing Address
First Line	:	2550 ALBANY AVE # 1056
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06117-2335
Country	:	US
Telephone Number	:
Fax Number	:	901-271-0155

Provider Business Practice Location Address
First Line	:	2550 ALBANY AVE # 1056
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06117-2335
Country	:	US
Telephone Number	:	617-869-0135
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2010
Last Update Date	:	08/28/2024

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