Provider Demographics
NPI:1629148945
Name:LISAN, DAVID (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:LISAN
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 1:913 MONTGOMERY AVE
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19072-1501
Mailing Address - Country:US
Mailing Address - Phone:610-664-3400
Mailing Address - Fax:610-664-8482
Practice Address - Street 1:913 MONTGOMERY AVE
Practice Address - Street 2:
Practice Address - City:PENN VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19072-1501
Practice Address - Country:US
Practice Address - Phone:610-664-3400
Practice Address - Fax:610-664-8482
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT007501L225100000X
FLOS7820208D00000X
PADAPT001519225100000X
FLPT21515225100000X
PAOS009840L208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA37813Medicare PIN
PA063841YVUFMedicare PIN
PAG79814Medicare UPIN