Healthcare Provider Details

I. General information

NPI: 1457330615
Provider Name (Legal Business Name): VICTOR KISSIL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2006
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19636 N 27TH AVE SUITE 303
PHOENIX AZ
85027-4013
US

IV. Provider business mailing address

PO BOX 39179
PHOENIX AZ
85069-9179
US

V. Phone/Fax

Practice location:
  • Phone: 623-879-8161
  • Fax: 623-879-9204
Mailing address:
  • Phone: 602-395-0718
  • Fax: 602-277-8146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number3735
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: