Provider Demographics
NPI:1003848797
Name:LISH, JEFFREY R (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:R
Last Name:LISH
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 1:984 MEDICAL DR STE 1
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-4712
Mailing Address - Country:US
Mailing Address - Phone:435-723-5248
Mailing Address - Fax:435-723-5240
Practice Address - Street 1:984 MEDICAL DR STE 1
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-4712
Practice Address - Country:US
Practice Address - Phone:435-723-5248
Practice Address - Fax:877-395-5866
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT178575-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870282100012Medicaid
UT000010826Medicare ID - Type Unspecified
UTD87682Medicare UPIN