Provider Demographics
NPI:1124094958
Name:LISCH, MARK S (DPM)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:LISCH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16918
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76162-0918
Mailing Address - Country:US
Mailing Address - Phone:323-686-8418
Mailing Address - Fax:
Practice Address - Street 1:6816 SHADOW CREEK CT
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4522
Practice Address - Country:US
Practice Address - Phone:832-368-6841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0787213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX085279001Medicaid
TX82Y991OtherBCBS
TX092841802Medicaid
TX4524710001Medicare NSC
TX00T49RMedicare PIN
TX480001802Medicare PIN
TX085279001Medicaid
TX82Y991Medicare PIN