Provider Demographics
NPI:1194868091
Name:LISIAK, JOHN JR (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:LISIAK
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:844 ELM ST
Mailing Address - Street 2:
Mailing Address - City:OLYPHANT
Mailing Address - State:PA
Mailing Address - Zip Code:18447-2136
Mailing Address - Country:US
Mailing Address - Phone:972-922-1342
Mailing Address - Fax:
Practice Address - Street 1:611 MORGAN HWY
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-9128
Practice Address - Country:US
Practice Address - Phone:570-585-6700
Practice Address - Fax:570-585-6714
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013862207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine