Provider Demographics
NPI:1265481204
Name:LISTON, WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
Last Name:LISTON
Suffix:
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 1:500 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1569
Mailing Address - Country:US
Mailing Address - Phone:906-483-1040
Mailing Address - Fax:906-483-1043
Practice Address - Street 1:500 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-1569
Practice Address - Country:US
Practice Address - Phone:906-483-1040
Practice Address - Fax:906-483-1043
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI51012076208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114387150Medicaid
MI0C16002OtherMEDICARE GROUP
MIWL012076OtherBLUECROSS STATE ID
MI0829560001OtherMEDICARE DME
MIC70764Medicare UPIN
MI0C16002060Medicare PIN