Provider Demographics
NPI:1740394600
Name:LISWOOD, PAUL JASON (DPM)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JASON
Last Name:LISWOOD
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 1:7212 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-2552
Mailing Address - Country:US
Mailing Address - Phone:718-745-0256
Mailing Address - Fax:718-833-0505
Practice Address - Street 1:7212 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-2552
Practice Address - Country:US
Practice Address - Phone:718-745-0256
Practice Address - Fax:718-833-0505
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNOO5182213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02012820Medicaid
NYP12701Medicare PIN
NYU55393Medicare UPIN