Provider Demographics
NPI:1205962297
Name:WANCIER, ZISALO (MD)
Entity type:Individual
Prefix:
First Name:ZISALO
Middle Name:
Last Name:WANCIER
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 1:516 VALLEY BROOK AVE
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07071-1930
Mailing Address - Country:US
Mailing Address - Phone:201-935-3322
Mailing Address - Fax:201-935-9196
Practice Address - Street 1:516 VALLEY BROOK AVE
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:NJ
Practice Address - Zip Code:07071-1930
Practice Address - Country:US
Practice Address - Phone:201-935-3322
Practice Address - Fax:201-935-9196
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA029298002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ444937Medicare ID - Type UnspecifiedPSYCHIATRIST