Healthcare Provider Details

I. General information

NPI: 1063704294
Provider Name (Legal Business Name): JESSE VISLISEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2011
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 CURVE CREST BLVD W
STILLWATER MN
55082
US

IV. Provider business mailing address

1719 TOWER DR W STE 100
STILLWATER MN
55082-7512
US

V. Phone/Fax

Practice location:
  • Phone: 651-275-3000
  • Fax: 651-275-3032
Mailing address:
  • Phone: 651-275-3000
  • Fax: 651-275-3032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License Number60618
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number60618
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: