Provider Demographics
NPI:1104869684
Name:PISKUN, MICHAEL A (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:PISKUN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 BETHEL RD
Mailing Address - Street 2:
Mailing Address - City:SOMERS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08244-2188
Mailing Address - Country:US
Mailing Address - Phone:609-927-8746
Mailing Address - Fax:609-601-1406
Practice Address - Street 1:403 BETHEL RD
Practice Address - Street 2:
Practice Address - City:SOMERS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08244-2188
Practice Address - Country:US
Practice Address - Phone:609-927-8746
Practice Address - Fax:609-601-1406
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08050100208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ208075502OtherTAX ID
NJ25MA08050100OtherNJ LICENSE
NJ106682Medicare PIN
NJI53559Medicare UPIN