Provider Demographics
NPI:1508973538
Name:LISTELLO, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:LISTELLO
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 1:3200 EAGLE PARK DR NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-7057
Mailing Address - Country:US
Mailing Address - Phone:616-285-9090
Mailing Address - Fax:616-285-7947
Practice Address - Street 1:3200 EAGLE PARK DR NE
Practice Address - Street 2:STE 102
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7057
Practice Address - Country:US
Practice Address - Phone:616-285-9090
Practice Address - Fax:616-285-7947
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062432207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3207721Medicaid
MI2904154311OtherBCBS OF MICHIGAN
MI3207721Medicaid
MI2904154311OtherBCBS OF MICHIGAN
0D16122011Medicare ID - Type Unspecified