Provider Demographics
NPI:1861574485
Name:LISBY, MARK D (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:LISBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10122 E 10TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-2663
Practice Address - Country:US
Practice Address - Phone:317-355-5717
Practice Address - Fax:317-355-3760
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2021-06-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01038785A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN08017984OtherRAILROAD MEDICARE
INP01678723OtherRR MEDICARE
IN0000002191OtherANTHEM LEGACY
IN100095430Medicaid
IN0000002191OtherANTHEM LEGACY
INP01678723OtherRR MEDICARE