Provider Demographics
NPI:1982682571
Name:LISZKA, BOZENNA M (MD)
Entity Type:Individual
Prefix:
First Name:BOZENNA
Middle Name:M
Last Name:LISZKA
Suffix:
Gender:F
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:LAUREL FORK
Mailing Address - State:VA
Mailing Address - Zip Code:24352-0009
Mailing Address - Country:US
Mailing Address - Phone:276-398-1200
Mailing Address - Fax:276-398-2094
Practice Address - Street 1:40 WILEY DRIVE
Practice Address - Street 2:
Practice Address - City:FERRUM
Practice Address - State:VA
Practice Address - Zip Code:24088
Practice Address - Country:US
Practice Address - Phone:540-365-4469
Practice Address - Fax:540-365-4272
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101053961207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00294696OtherMEDICARE RAILROAD
VAMC11621Medicare PIN
VAP00294696OtherMEDICARE RAILROAD
VA009510C63Medicare PIN