Provider Demographics
NPI:1356506166
Name:KISSWANY, MARY S (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:KISSWANY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0194
Mailing Address - Fax:
Practice Address - Street 1:1125 W HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-5004
Practice Address - Country:US
Practice Address - Phone:225-621-2975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-21
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08436700208M00000X
LA000246208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0172146Medicaid
NJP00829442OtherRR MEDICARE-TEANECK
NJP00667653OtherRAILROAD MEDICARE
NJ48090-NON PAROtherUHP-PHYS ASSOC OF TEANECK
NJP00667653OtherRAILROAD MEDICARE
NJP00829442OtherRR MEDICARE-TEANECK
NJ130304UXWMedicare PIN
NJ0172146Medicaid