Provider Demographics
NPI:1295737823
Name:LISAK, ALICJA D (MD)
Entity type:Individual
Prefix:
First Name:ALICJA
Middle Name:D
Last Name:LISAK
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:W129N7055 NORTHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-0538
Mailing Address - Country:US
Mailing Address - Phone:262-253-5400
Mailing Address - Fax:
Practice Address - Street 1:W129N7055 NORTHFIELD DR
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-0538
Practice Address - Country:US
Practice Address - Phone:262-253-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1295737823Medicaid
G23858Medicare UPIN
WIK400113994Medicare PIN