Provider Demographics
NPI:1558372912
Name:LYSKOWSKI, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:LYSKOWSKI
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:PO BOX 1027
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-1027
Mailing Address - Country:US
Mailing Address - Phone:573-681-3767
Mailing Address - Fax:573-761-6947
Practice Address - Street 1:2701 W EDGEWOOD DR
Practice Address - Street 2:SUITE 101
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5889
Practice Address - Country:US
Practice Address - Phone:573-634-5303
Practice Address - Fax:573-761-6888
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1B982084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201418233Medicaid
MO131890007Medicare PIN
MOA11380Medicare UPIN