Healthcare Provider Details

I. General information

NPI: 1043236706
Provider Name (Legal Business Name): RUDOLF W CISCO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 SHERWOOD PARK DR NE
GAINESVILLE GA
30501-3445
US

IV. Provider business mailing address

1224 SHERWOOD PARK DR NE
GAINESVILLE GA
30501-3445
US

V. Phone/Fax

Practice location:
  • Phone: 770-287-0606
  • Fax: 770-287-0159
Mailing address:
  • Phone: 770-287-0606
  • Fax: 770-287-0159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number000596
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: