Provider Demographics
NPI:1457330615
Name:KISSIL, VICTOR (DO)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:
Last Name:KISSIL
Suffix:
Gender:M
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:PO BOX 39179
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85069-9179
Mailing Address - Country:US
Mailing Address - Phone:602-395-0718
Mailing Address - Fax:602-277-8146
Practice Address - Street 1:19636 N 27TH AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4013
Practice Address - Country:US
Practice Address - Phone:623-879-8161
Practice Address - Fax:623-879-9204
Is Sole Proprietor?:No
Enumeration Date:2006-01-15
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3735174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ636376Medicaid
F93228Medicare UPIN
AZZ120928Medicare PIN