Provider Demographics
NPI:1326301128
Name:LISCANO, BEN (MD)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:LISCANO
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 1:323 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:SD
Mailing Address - Zip Code:57042-3200
Mailing Address - Country:US
Mailing Address - Phone:605-256-6551
Mailing Address - Fax:605-256-6469
Practice Address - Street 1:323 SW 10TH ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:SD
Practice Address - Zip Code:57042-3200
Practice Address - Country:US
Practice Address - Phone:605-256-6551
Practice Address - Fax:605-256-6469
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD9561207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine