Provider Demographics
NPI:1821036500
Name:LISK, JEROME P (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:P
Last Name:LISK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 MEDPARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76208-6982
Mailing Address - Country:US
Mailing Address - Phone:940-383-1770
Mailing Address - Fax:877-319-1848
Practice Address - Street 1:3120 MEDPARK DR STE 100
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76208-6982
Practice Address - Country:US
Practice Address - Phone:940-383-1770
Practice Address - Fax:877-319-1848
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040298252084N0400X
TXR10742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX366511901Medicaid
TXP01773741OtherRAIL ROAD MEDICARE
MO207238106Medicaid
193247OtherBLUE CROSS/BLUE SHIELD
CAP00890011OtherMEDICARE RAILROAD
TXP01773741OtherRAIL ROAD MEDICARE
I25519Medicare UPIN
MO207238106Medicaid