Provider Demographics
NPI:1366442048
Name:CHISCANO, KRISTIE A (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:A
Last Name:CHISCANO
Suffix:
Gender:F
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:PO BOX 596
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78292-0596
Mailing Address - Country:US
Mailing Address - Phone:210-212-4114
Mailing Address - Fax:210-212-4012
Practice Address - Street 1:315 N SAN SABA
Practice Address - Street 2:SUITE 1240
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3154
Practice Address - Country:US
Practice Address - Phone:210-212-4114
Practice Address - Fax:210-212-4012
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2009-03-18
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-27
Provider Licenses
StateLicense IDTaxonomies
TXL8648208C00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170376101Medicaid
TX170376101Medicaid