Healthcare Provider Details

I. General information

NPI: 1174725303
Provider Name (Legal Business Name): TIMOTHY STEPHEN LISHNAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 07/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-0001
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06030-0001
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-4477
  • Fax: 860-679-8770
Mailing address:
  • Phone: 860-679-4477
  • Fax: 860-679-8770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number042.0012118
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042.0012118
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: