Provider Demographics
NPI:1922268697
Name:KLISIEWICZ, SEBASTIAN (DO)
Entity Type:Individual
Prefix:DR
First Name:SEBASTIAN
Middle Name:
Last Name:KLISIEWICZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9250 CORKSCREW RD STE 15
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-3217
Mailing Address - Country:US
Mailing Address - Phone:773-895-0708
Mailing Address - Fax:855-398-9437
Practice Address - Street 1:9250 CORKSCREW RD STE 15
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928
Practice Address - Country:US
Practice Address - Phone:239-687-3199
Practice Address - Fax:855-398-9437
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12803208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013013900Medicaid