Provider Demographics
NPI:1366468670
Name:LISKER MELMAN, MAURICIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MAURICIO
Middle Name:
Last Name:LISKER MELMAN
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 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8124
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-454-8141
Mailing Address - Fax:314-454-5108
Practice Address - Street 1:4921 PARKVIEW PL STE 8C
Practice Address - Street 2:STE 8C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-454-8141
Practice Address - Fax:314-454-5108
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000146365207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILENROLLEDMedicaid
MO204878508Medicaid
MO296010183Medicare PIN
IL$$$$$$$$$Medicaid