Provider Demographics
NPI:1083973556
Name:LISCHALK, JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:LISCHALK
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 1:30 SHELBURNE RD
Mailing Address - Street 2:DEPARTMENT OF MEDICINE
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3628
Mailing Address - Country:US
Mailing Address - Phone:203-276-7485
Mailing Address - Fax:203-276-7368
Practice Address - Street 1:3800 RESERVOIR RD NW DEPT OF
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-2113
Practice Address - Country:US
Practice Address - Phone:202-444-3320
Practice Address - Fax:202-444-3786
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DCMD0449172085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program