Healthcare Provider Details

I. General information

NPI: 1861574485
Provider Name (Legal Business Name): MARK D LISBY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10122 E 10TH ST SUITE 100
INDIANAPOLIS IN
46229-2663
US

IV. Provider business mailing address

6626 E 75TH ST SUITE 500
INDIANAPOLIS IN
46250-2805
US

V. Phone/Fax

Practice location:
  • Phone: 317-355-5717
  • Fax: 317-355-3760
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01038785A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: