Provider Demographics
NPI:1720183866
Name:LIZAK, RICHARD EDWIN (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:EDWIN
Last Name:LIZAK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-3107
Mailing Address - Country:US
Mailing Address - Phone:601-483-5901
Mailing Address - Fax:601-483-7435
Practice Address - Street 1:1900 23RD AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3107
Practice Address - Country:US
Practice Address - Phone:601-483-5901
Practice Address - Fax:601-483-7435
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS476111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115179Medicaid
MS00115179Medicaid
MST21231Medicare UPIN