Provider Demographics
NPI:1447630199
Name:LISIECKI, JEFFREY LAWRENCE (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LAWRENCE
Last Name:LISIECKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 PARK AVE APT 1C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4264
Mailing Address - Country:US
Mailing Address - Phone:212-680-4626
Mailing Address - Fax:
Practice Address - Street 1:737 PARK AVE APT 1C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4264
Practice Address - Country:US
Practice Address - Phone:212-680-4626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS9341208200000X
MI4301107909390200000X
NY314856208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program