Healthcare Provider Details

I. General information

NPI: 1215048590
Provider Name (Legal Business Name): DR. MICHAEL ANTHONY CISZEK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5222 N CLARK ST
CHICAGO IL
60640-2377
US

IV. Provider business mailing address

5222 N CLARK ST
CHICAGO IL
60640-2377
US

V. Phone/Fax

Practice location:
  • Phone: 773-275-2538
  • Fax: 773-275-0344
Mailing address:
  • Phone: 773-275-2538
  • Fax: 773-275-0344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: