Provider Demographics
NPI:1619968872
Name:KYSELKA, LUANA J (MD)
Entity Type:Individual
Prefix:DR
First Name:LUANA
Middle Name:J
Last Name:KYSELKA
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 1:2877 CROOKS RD
Mailing Address - Street 2:STE D
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4717
Mailing Address - Country:US
Mailing Address - Phone:248-643-6634
Mailing Address - Fax:248-643-7165
Practice Address - Street 1:2877 CROOKS RD
Practice Address - Street 2:STE D
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4717
Practice Address - Country:US
Practice Address - Phone:248-643-6634
Practice Address - Fax:248-643-7165
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043787207VG0400X, 207V00000X, 207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2733930Medicaid
MIMI3186001Medicare PIN
MI2733930Medicaid