Provider Demographics
NPI:1700889003
Name:LISKO, BRADLEY ALEX (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:ALEX
Last Name:LISKO
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 1:110 POLARIS PKWY
Mailing Address - Street 2:STE 250
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-8074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:614-865-4900
Practice Address - Street 1:110 POLARIS PKWY
Practice Address - Street 2:STE 250
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-8074
Practice Address - Country:US
Practice Address - Phone:614-865-4800
Practice Address - Fax:614-865-4900
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2021-04-29
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-08-04
Provider Licenses
StateLicense IDTaxonomies
OH35063629L208000000X
OH350633629L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0154069Medicaid
OH0790243Medicare ID - Type Unspecified
OHB13114Medicare UPIN