Provider Demographics
NPI:1528558939
Name:LIS, JONATHAN BRIAN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BRIAN
Last Name:LIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:125 NEW MILFORD TPKE
Mailing Address - Street 2:
Mailing Address - City:NEW PRESTON MARBLE DALE
Mailing Address - State:CT
Mailing Address - Zip Code:06777-1703
Mailing Address - Country:US
Mailing Address - Phone:860-868-8932
Mailing Address - Fax:860-868-7310
Practice Address - Street 1:140 GRANDVIEW AVE STE L04
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2518
Practice Address - Country:US
Practice Address - Phone:860-868-8932
Practice Address - Fax:860-868-7310
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT67341207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty