Provider Demographics
NPI:1174591804
Name:LISTHAUS, MICHELLE BETH (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:BETH
Last Name:LISTHAUS
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 1:990 STEWART AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4822
Mailing Address - Country:US
Mailing Address - Phone:516-222-4294
Mailing Address - Fax:516-222-4880
Practice Address - Street 1:990 STEWART AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4822
Practice Address - Country:US
Practice Address - Phone:516-222-4294
Practice Address - Fax:516-222-4880
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1961082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01506385Medicaid
NY01506385Medicaid
NY40J971Medicare ID - Type Unspecified