Provider Demographics
NPI:1194790204
Name:LISZEK, MARY JO (MD)
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:LISZEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:FAHEY BLDG., RM. 119)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-8563
Mailing Address - Fax:708-216-0346
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:FAHEY BLDG., RM. 119)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-8563
Practice Address - Fax:708-216-0346
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079155208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079155Medicaid
K21682Medicare ID - Type Unspecified
F32616Medicare UPIN