Provider Demographics
NPI:1043236706
Name:CISCO, RUDOLF W (DPM)
Entity type:Individual
Prefix:DR
First Name:RUDOLF
Middle Name:W
Last Name:CISCO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1224 SHERWOOD PARK DR NE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3445
Mailing Address - Country:US
Mailing Address - Phone:770-287-0606
Mailing Address - Fax:770-287-0159
Practice Address - Street 1:1224 SHERWOOD PARK DR NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3445
Practice Address - Country:US
Practice Address - Phone:770-287-0606
Practice Address - Fax:770-287-0159
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000596213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00409274AMedicaid
GAU20478Medicare UPIN
GA00409274AMedicaid