Provider Demographics
NPI:1821200239
Name:LISTER, MATTHEW THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:THOMAS
Last Name:LISTER
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 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:1 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1375
Practice Address - Country:US
Practice Address - Phone:608-287-2100
Practice Address - Fax:608-833-6932
Is Sole Proprietor?:No
Enumeration Date:2007-05-06
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50324-20207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34926700Medicaid
WIP00609990OtherRR MEDICARE
WI34926700Medicaid
WIP00609990OtherRR MEDICARE