Provider Demographics
NPI:1710961990
Name:LISOWSKY, TARAS (DO)
Entity Type:Individual
Prefix:DR
First Name:TARAS
Middle Name:
Last Name:LISOWSKY
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 1:11300 E 13 MILE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2500
Mailing Address - Country:US
Mailing Address - Phone:586-777-6170
Mailing Address - Fax:586-777-6582
Practice Address - Street 1:11300 E 13 MILE RD STE 1
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2500
Practice Address - Country:US
Practice Address - Phone:586-777-6170
Practice Address - Fax:586-777-6582
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H217350OtherBLUE SHIELD
MI1710961990Medicaid
MI0M92440045Medicare PIN
MI700H217350OtherBLUE SHIELD