Provider Demographics
NPI:1306909825
Name:SUGENG, LISSA (MD, MPH)
Entity type:Individual
Prefix:
First Name:LISSA
Middle Name:
Last Name:SUGENG
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 208017
Mailing Address - Street 2:YALE SCHOOL OF MEDICINE, SECTION OF CARDIOLOGY
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520-8017
Mailing Address - Country:US
Mailing Address - Phone:203-785-2469
Mailing Address - Fax:
Practice Address - Street 1:135 COLLEGE ST FL 3
Practice Address - Street 2:SUITE 301
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-2483
Practice Address - Country:US
Practice Address - Phone:203-785-6460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098586207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098586Medicaid
IL036098586Medicaid