Provider Demographics
NPI:1023637741
Name:LISIESKI, MICHAEL JAMES
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:LISIESKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1938 PERTH ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43607-1417
Mailing Address - Country:US
Mailing Address - Phone:724-493-8474
Mailing Address - Fax:
Practice Address - Street 1:3333 GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2426
Practice Address - Country:US
Practice Address - Phone:419-383-5502
Practice Address - Fax:419-383-5515
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.148139207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine