Provider Demographics
NPI:1780683417
Name:LISKOV, DAVID (MD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:LISKOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 NORTHAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4560
Mailing Address - Country:US
Mailing Address - Phone:570-287-2900
Mailing Address - Fax:570-300-1829
Practice Address - Street 1:562 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-3721
Practice Address - Country:US
Practice Address - Phone:570-552-3900
Practice Address - Fax:570-287-6733
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-034887-E2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010825390002Medicaid
PA0010825390003Medicaid
PAC29229Medicare UPIN
PA260046011Medicare ID - Type UnspecifiedRAILROAD
PALI080132Medicare ID - Type Unspecified