Provider Demographics
NPI:1295958312
Name:LISTER, DOUGLAS S (DPM)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:S
Last Name:LISTER
Suffix:
Gender:M
Credentials:DPM
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 34120
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89533-4120
Mailing Address - Country:US
Mailing Address - Phone:775-747-5050
Mailing Address - Fax:775-329-8596
Practice Address - Street 1:2720 HOMESTEAD ROAD
Practice Address - Street 2:SUITE 50
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-4885
Practice Address - Country:US
Practice Address - Phone:435-604-0449
Practice Address - Fax:435-649-9202
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE41920213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000065013Medicaid
UT6619665-0501OtherUTAH LICENSE
UT000065013Medicaid