Provider Demographics
NPI:1639330541
Name:CISLO, SUSAN C (DO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:CISLO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3417 VALLE VERDE DR
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-2414
Mailing Address - Country:US
Mailing Address - Phone:707-255-4172
Mailing Address - Fax:707-255-2605
Practice Address - Street 1:3417 VALLE VERDE DR
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2414
Practice Address - Country:US
Practice Address - Phone:707-255-4172
Practice Address - Fax:707-255-2605
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8069204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A8069OtherCA LICENSE