Provider Demographics
NPI:1316976012
Name:LISKO, JAMES R (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:LISKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 E. NIZHONI BLVD.
Mailing Address - Street 2:BOX 1337
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:505-726-8557
Practice Address - Street 1:516 E. NIZHONI BLVD.
Practice Address - Street 2:BOX 1337
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-1337
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-726-8557
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 58682207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2872587Medicaid
AZ775075Medicaid
TX8HBL19Medicare ID - Type UnspecifiedHSZ001
TX8HBL18Medicare ID - Type UnspecifiedHSZ006
NM2872587Medicaid
TX8HC223Medicare ID - Type UnspecifiedHSZ197
F07366Medicare UPIN
TX8HBL20Medicare ID - Type UnspecifiedHSZ002