Healthcare Provider Details

I. General information

NPI: 1790759934
Provider Name (Legal Business Name): MARK ANTHONY LIZAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MEDICAL CENTER DRIVE
SUPPLY NC
28462-3350
US

IV. Provider business mailing address

14 MEDICAL CENTER DRIVE
SUPPLY NC
28462-3350
US

V. Phone/Fax

Practice location:
  • Phone: 910-754-2920
  • Fax: 910-754-2268
Mailing address:
  • Phone: 910-754-2920
  • Fax: 910-754-2268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number35760
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: