Provider Demographics
NPI:1457486300
Name:CISCO, MICHAEL JOSHUA (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSHUA
Last Name:CISCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 WELCH RD
Mailing Address - Street 2:PACKARD CHILDRENS HOSPITAL AT STANFORD
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-1601
Mailing Address - Country:US
Mailing Address - Phone:650-723-7913
Mailing Address - Fax:
Practice Address - Street 1:725 WELCH RD
Practice Address - Street 2:PACKARD CHILDRENS HOSPITAL AT STANFORD
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1601
Practice Address - Country:US
Practice Address - Phone:650-723-7913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA873992080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A873990Medicaid
CAI13890Medicare UPIN
CAI13890Medicare UPIN