Provider Demographics
NPI:1780779207
Name:BRESLAUER, LISA (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:BRESLAUER
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 1:417 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07928-2105
Mailing Address - Country:US
Mailing Address - Phone:973-635-5050
Mailing Address - Fax:973-635-4567
Practice Address - Street 1:417 MAIN ST
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:NJ
Practice Address - Zip Code:07928-2105
Practice Address - Country:US
Practice Address - Phone:973-635-5050
Practice Address - Fax:973-635-4567
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07719400207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ082364BV6Medicare ID - Type UnspecifiedMEDICARE
NJH53108Medicare UPIN