Provider Demographics
NPI:1649373580
Name:BOURET, LISSETTE MARIE (MD)
Entity type:Individual
Prefix:
First Name:LISSETTE
Middle Name:MARIE
Last Name:BOURET
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 1:219 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-5524
Mailing Address - Country:US
Mailing Address - Phone:781-322-7300
Mailing Address - Fax:
Practice Address - Street 1:219 CENTRE ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5524
Practice Address - Country:US
Practice Address - Phone:781-322-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14725207Q00000X
MA265252207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine