Provider Demographics
NPI:1174725303
Name:LISHNAK, TIMOTHY STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:STEPHEN
Last Name:LISHNAK
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 1:263 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-0001
Mailing Address - Country:US
Mailing Address - Phone:860-679-4477
Mailing Address - Fax:860-679-8770
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-4477
Practice Address - Fax:860-679-8770
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.0012118207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1174725303Medicaid
1174725303OtherNPI
1174725303OtherNPI