Provider Demographics
NPI:1235122631
Name:FISCELLA, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:FISCELLA
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 1:1410 59TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-4607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:941-794-8017
Practice Address - Street 1:1410 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4607
Practice Address - Country:US
Practice Address - Phone:941-792-1477
Practice Address - Fax:941-794-8017
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0015053208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5355285OtherAETNA
D54792Medicare UPIN
FL5355285OtherAETNA