Provider Demographics
NPI:1043258353
Name:LISTER, MARK ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:LISTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1 CLARA MAASS DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-3550
Mailing Address - Country:US
Mailing Address - Phone:973-844-1340
Mailing Address - Fax:973-450-5964
Practice Address - Street 1:1 CLARA MAASS DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-3550
Practice Address - Country:US
Practice Address - Phone:973-844-1340
Practice Address - Fax:973-450-5964
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04176200207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1515608Medicaid
NJB14523Medicare UPIN
NJ536525Medicare PIN