Provider Demographics
NPI:1386616696
Name:LISSENDEN, CAROLKAY (MD)
Entity type:Individual
Prefix:DR
First Name:CAROLKAY
Middle Name:
Last Name:LISSENDEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 WILD HEDGE LANE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAINSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07092
Mailing Address - Country:US
Mailing Address - Phone:908-232-2935
Mailing Address - Fax:908-232-3980
Practice Address - Street 1:135 WILD HEDGE LANE
Practice Address - Street 2:
Practice Address - City:MOUNTAINSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07092-2520
Practice Address - Country:US
Practice Address - Phone:908-232-2935
Practice Address - Fax:908-232-3980
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ21738208000000X
NY950721208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1231804Medicaid
NJ1231804Medicaid
LI408227Medicare ID - Type Unspecified