Provider Demographics
NPI:1619065224
Name:DAVID W. KISIOLEK, O.D., S.C.
Entity Type:Organization
Organization Name:DAVID W. KISIOLEK, O.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:KISIOLEK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:920-565-3991
Mailing Address - Street 1:300 AUDUBON RD
Mailing Address - Street 2:
Mailing Address - City:HOWARDS GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53083-1280
Mailing Address - Country:US
Mailing Address - Phone:920-565-3991
Mailing Address - Fax:920-565-4404
Practice Address - Street 1:300 AUDUBON RD
Practice Address - Street 2:
Practice Address - City:HOWARDS GROVE
Practice Address - State:WI
Practice Address - Zip Code:53083-1280
Practice Address - Country:US
Practice Address - Phone:920-565-3991
Practice Address - Fax:920-565-4404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1742152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38514400Medicaid
WIT62421Medicare UPIN
WI38514400Medicaid
WI000087384Medicare ID - Type Unspecified