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General NPI Number Information
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NPI Number | 1124094958
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Entity Type | Individual
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Provider Name | MARK S LISCH DPM
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Gender | Male
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Dates
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Enumeration Date | 02/23/2006
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Last Update Date | 10/04/2021
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Provider Practice Location Address
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Address Line | 6816 SHADOW CREEK CT
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City | FORT WORTH
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State | TX
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Zip | 76132-4522
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Country | US
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Telephone | 832-368-6841
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 16918
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City | FORT WORTH
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State | TX
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Zip | 76162-0918
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Country | US
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Telephone | 323-686-8418
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 0787
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License Number State | TX
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