Provider Demographics
NPI:1528007028
Name:LISTWAN, WILLIAM J (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:J
Last Name:LISTWAN
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:N19W26595 HONEYSUCKLE CT
Mailing Address - Street 2:UNIT A
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-5414
Mailing Address - Country:US
Mailing Address - Phone:414-750-4133
Mailing Address - Fax:
Practice Address - Street 1:555 S 108TH ST
Practice Address - Street 2:QUAD-MED
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-1100
Practice Address - Country:US
Practice Address - Phone:414-566-8210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16862207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31206600Medicaid
WI31206600Medicaid
WI042T 73-601Medicare ID - Type Unspecified