Provider Demographics
NPI:1376536037
Name:LISMAN, LARRY L
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:L
Last Name:LISMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 OHIO BLVD
Mailing Address - Street 2:SUITE 127
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-2239
Mailing Address - Country:US
Mailing Address - Phone:812-234-8261
Mailing Address - Fax:812-234-8262
Practice Address - Street 1:7430 N SHADELAND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2070
Practice Address - Country:US
Practice Address - Phone:317-596-9804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030377207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100251430Medicaid
IN179570Medicare ID - Type Unspecified
IN100251430Medicaid