Provider Demographics
NPI:1164433413
Name:GHISELLI, ROBERT W (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:GHISELLI
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 1:3301 C ST
Mailing Address - Street 2:SUITE #200-E
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-3300
Mailing Address - Country:US
Mailing Address - Phone:916-447-6267
Mailing Address - Fax:916-447-0621
Practice Address - Street 1:3301 C ST
Practice Address - Street 2:SUITE #200-E
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-3300
Practice Address - Country:US
Practice Address - Phone:916-447-6267
Practice Address - Fax:916-447-0621
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70255174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G702550Medicaid
CA00G702550Medicaid
CAA12200Medicare ID - Type Unspecified