Healthcare Provider Details

I. General information

NPI: 1770089005
Provider Name (Legal Business Name): TOMAS E LISKUTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5316 S WOODROW ST STE 200
MURRAY UT
84107-5479
US

IV. Provider business mailing address

5316 S WOODROW ST STE 200
MURRAY UT
84107-5479
US

V. Phone/Fax

Practice location:
  • Phone: 801-747-1020
  • Fax: 801-747-1023
Mailing address:
  • Phone: 801-747-1020
  • Fax: 801-747-1023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number13901333-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number2023006696
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: