Provider Demographics
NPI:1083757439
Name:LISLE, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:LISLE
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 1:192 TILLEY DR
Mailing Address - Street 2:ORTHOPAEDIC SPECIALTY CENTER
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-4440
Mailing Address - Country:US
Mailing Address - Phone:802-847-2663
Mailing Address - Fax:
Practice Address - Street 1:192 TILLEY DR
Practice Address - Street 2:ORTHOPAEDIC SPECIALTY CENTER
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-4440
Practice Address - Country:US
Practice Address - Phone:802-847-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0011500207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8475287Medicaid
WAG8872436Medicare PIN
WAG8871768Medicare PIN
WAG8864483Medicare PIN