Provider Demographics
NPI:1487817375
Name:LISTON, BRAD ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:ALAN
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 1:1908 N 14TH ST STE 204
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2039
Mailing Address - Country:US
Mailing Address - Phone:580-763-5900
Mailing Address - Fax:
Practice Address - Street 1:1908 N 14TH ST STE 204
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2039
Practice Address - Country:US
Practice Address - Phone:580-763-5900
Practice Address - Fax:580-763-5901
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4659207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine