Healthcare Provider Details

I. General information

NPI: 1356194351
Provider Name (Legal Business Name): LUKE RICHARD LISH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2024
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 W FLETCHER ST
HAXTUN CO
80731-2737
US

IV. Provider business mailing address

235 W FLETCHER ST
HAXTUN CO
80731-2737
US

V. Phone/Fax

Practice location:
  • Phone: 970-774-6123
  • Fax:
Mailing address:
  • Phone: 812-827-6698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0078447
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number1356194351
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: