1295958312 NPI number — DOUGLAS S LISTER DPM

Table of content: DOUGLAS S LISTER DPM (NPI 1295958312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295958312 NPI number — DOUGLAS S LISTER DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LISTER
Provider First Name:
DOUGLAS
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295958312
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 34120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89533-4120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-747-5050
Provider Business Mailing Address Fax Number:
775-329-8596

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2720 HOMESTEAD ROAD
Provider Second Line Business Practice Location Address:
SUITE 50
Provider Business Practice Location Address City Name:
PARK CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84098-4885
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-604-0449
Provider Business Practice Location Address Fax Number:
435-649-9202
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  E41920 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000065013 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6619665-0501 . This is a "UTAH LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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