Provider Demographics
NPI:1952470874
Name:LISSKA, LAWRENCE ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:ALBERT
Last Name:LISSKA
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 1:4130 SALISBURY RD
Mailing Address - Street 2:SUITE 1900
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8031
Mailing Address - Country:US
Mailing Address - Phone:904-281-0234
Mailing Address - Fax:904-281-0236
Practice Address - Street 1:4130 SALISBURY RD
Practice Address - Street 2:SUITE 1900
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8031
Practice Address - Country:US
Practice Address - Phone:904-281-0234
Practice Address - Fax:904-281-0236
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0029258207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004628900Medicaid
FL15453XMedicare PIN
FL004628900Medicaid
FLD52591Medicare UPIN