Healthcare Provider Details

I. General information

NPI: 1780683417
Provider Name (Legal Business Name): DAVID LISKOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

562 WYOMING AVE
KINGSTON PA
18704-3721
US

IV. Provider business mailing address

512 NORTHAMPTON ST
EDWARDSVILLE PA
18704-4560
US

V. Phone/Fax

Practice location:
  • Phone: 570-552-3900
  • Fax: 570-287-6733
Mailing address:
  • Phone: 570-287-2900
  • Fax: 570-300-1829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberMD-034887-E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: