Provider Demographics
NPI:1053329839
Name:LISOWSKY, MYKOLA (DPM)
Entity Type:Individual
Prefix:
First Name:MYKOLA
Middle Name:
Last Name:LISOWSKY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 N DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:HARVARD
Mailing Address - State:IL
Mailing Address - Zip Code:60033-3683
Mailing Address - Country:US
Mailing Address - Phone:815-943-8122
Mailing Address - Fax:
Practice Address - Street 1:1819 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:HARVARD
Practice Address - State:IL
Practice Address - Zip Code:60033-3683
Practice Address - Country:US
Practice Address - Phone:815-943-8122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
BL7382625OtherDEA
U85638Medicare UPIN