Provider Demographics
NPI:1740379387
Name:LISLE, JAMES E (DPM)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:E
Last Name:LISLE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3474 LIBERTY RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4607
Mailing Address - Country:US
Mailing Address - Phone:503-588-8188
Mailing Address - Fax:503-588-0884
Practice Address - Street 1:3474 LIBERTY RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4607
Practice Address - Country:US
Practice Address - Phone:503-588-8188
Practice Address - Fax:503-588-0884
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR130213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR268243Medicaid
OR102503Medicare ID - Type Unspecified
ORT67855Medicare UPIN