Healthcare Provider Details

I. General information

NPI: 1124094958
Provider Name (Legal Business Name): MARK S LISCH DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6816 SHADOW CREEK CT
FORT WORTH TX
76132-4522
US

IV. Provider business mailing address

PO BOX 16918
FORT WORTH TX
76162-0918
US

V. Phone/Fax

Practice location:
  • Phone: 832-368-6841
  • Fax:
Mailing address:
  • Phone: 323-686-8418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0787
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: