Basic Information
| Provider Information | |||||||||
| NPI: | 1699752436 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CISLO | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | GEORGE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3434 HANCOCK BRIDGE PKWY | ||||||||
| Address2: | |||||||||
| City: | N FT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339037094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | 2395992625 | ||||||||
| Practice Location | |||||||||
| Address1: | 13823 TAMIAMI TRL | ||||||||
| Address2: | |||||||||
| City: | NORTH PORT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342872069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9418880770 | ||||||||
| FaxNumber: | 9418880778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 08/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS5665 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 80241 | 01 | FL | BCBS | OTHER | 039219700 | 05 | FL | MEDICAID |