Provider Demographics
NPI:1295735561
Name:CHISDAK, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CHISDAK
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 1:52 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2120
Mailing Address - Country:US
Mailing Address - Phone:607-729-8845
Mailing Address - Fax:607-729-5574
Practice Address - Street 1:52 HARRISON ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2120
Practice Address - Country:US
Practice Address - Phone:607-729-8845
Practice Address - Fax:607-729-5574
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168967207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00845607Medicaid
NY00845607Medicaid
NYB35507Medicare UPIN