Provider Demographics
NPI:1124024500
Name:ZISOW, DAVID LESLIE (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LESLIE
Last Name:ZISOW
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 1:2005 ROCK SPRING RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FOREST HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21050-2621
Mailing Address - Country:US
Mailing Address - Phone:410-879-1139
Mailing Address - Fax:410-893-1158
Practice Address - Street 1:2005 ROCK SPRING RD
Practice Address - Street 2:SUITE 3
Practice Address - City:FOREST HILL
Practice Address - State:MD
Practice Address - Zip Code:21050-2621
Practice Address - Country:US
Practice Address - Phone:410-879-1139
Practice Address - Fax:410-893-1158
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0017174207VG0400X
FLME91824207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD972911900Medicaid
MDC57411Medicare UPIN
MD972911900Medicaid
MD164025ZCDMedicare PIN
MDS581Medicare PIN