Provider Demographics
NPI:1689786154
Name:LISCOW, DAVID MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:LISCOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:930 BLUE STAR HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-7758
Mailing Address - Country:US
Mailing Address - Phone:269-637-1115
Mailing Address - Fax:269-639-1314
Practice Address - Street 1:930 BLUE STAR HWY
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-7758
Practice Address - Country:US
Practice Address - Phone:269-637-1115
Practice Address - Fax:269-639-1314
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301048560207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080H06004OtherBCBSM
MI080027374OtherRR MEDICARE
MI1656193Medicaid
MI0131169OtherPHP/IBA
MIP53524OtherBCN
MI5468088OtherAETNA