Healthcare Provider Details

I. General information

NPI: 1831332279
Provider Name (Legal Business Name): SERGEI KALSOW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2009
Last Update Date: 07/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 KINGS HWY DEPARTMENT OF SURGERY
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

137 SW 54TH TERRACE
CAPE CORAL FL
33914
US

V. Phone/Fax

Practice location:
  • Phone: 318-675-6111
  • Fax: 318-675-6141
Mailing address:
  • Phone: 352-246-1775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number284010
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: