Provider Demographics
NPI:1639881881
Name:TELISMAN, MARK JOHN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:TELISMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35000 KAISER CT
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-3382
Mailing Address - Country:US
Mailing Address - Phone:440-269-4600
Mailing Address - Fax:
Practice Address - Street 1:35000 KAISER CT
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-3382
Practice Address - Country:US
Practice Address - Phone:440-269-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH279674163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice