MEDICARE: DR. BOAZ J LISSAUER 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	207W00000X	Ophthalmology Physician	208452	NY
2	207W00000X	Ophthalmology Physician	25MA07699200	NJ
3	2086S0122X	Plastic and Reconstructive Surgery Physician	25MA07699200	NJ
4	2086S0122X	Plastic and Reconstructive Surgery Physician	208452	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BL0482B310	OTHER	NY	FEDERAL BLUE CROSS BLUE S
2	7554155	OTHER		AETNA
3	BL0482B310	OTHER	NY	BLUE CROSS BLUE SHIELD
4	P2647045	OTHER		OXFORD
5	0498250	OTHER	NY	GHI
6	1000035875	OTHER	NY	AFFNITY HEALTH PLAN
7	208452	OTHER	NY	HIP
8	271252B	OTHER	NY	DIVISION 1181 MAGNACARE

General Provider Information

NPI Number	:	1639173123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BOAZ J LISSAUER MD

Provider Business Mailing Address
First Line	:	1036 PARK AVE
Second Line	:	SUITE 1C
City	:	NEW YORK
State	:	NY
Zip	:	10028-0971
Country	:	US
Telephone Number	:	212-717-2150
Fax Number	:	212-717-2154

Provider Business Practice Location Address
First Line	:	1036 PARK AVE
Second Line	:	SUITE 1C
City	:	NEW YORK
State	:	NY
Zip	:	10028-0971
Country	:	US
Telephone Number	:	212-717-2150
Fax Number	:	212-717-2154

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

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	06/25/2009

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