Provider Demographics
NPI:1891285417
Name:CISU, THEODORE ILIE (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:ILIE
Last Name:CISU
Suffix:
Gender:M
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:PO BOX 8310
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-0310
Mailing Address - Country:US
Mailing Address - Phone:540-345-3556
Mailing Address - Fax:540-566-3889
Practice Address - Street 1:70 MEDICAL CENTER CIR STE 208
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2273
Practice Address - Country:US
Practice Address - Phone:540-932-5926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101277959208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology