Provider Demographics
NPI:1477557445
Name:KISLA, TIMOTHY A (DO)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:A
Last Name:KISLA
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:1870 SILVER CROSS BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-8639
Mailing Address - Country:US
Mailing Address - Phone:815-485-2727
Mailing Address - Fax:815-485-3034
Practice Address - Street 1:1870 SILVER CROSS BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-8639
Practice Address - Country:US
Practice Address - Phone:815-485-2727
Practice Address - Fax:815-485-3034
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036097974207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097974Medicaid
ILP00061462OtherRAILROAD MEDICARE
ILG84221Medicare UPIN
ILK03665Medicare ID - Type Unspecified
ILK03666Medicare PIN