Provider Demographics
NPI:1194975334
Name:KSYCKI, MICHAEL F (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:F
Last Name:KSYCKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 NW 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1005
Mailing Address - Country:US
Mailing Address - Phone:305-585-1288
Mailing Address - Fax:305-585-0142
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-1288
Practice Address - Fax:305-585-0142
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10488208600000X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0005551-00Medicaid
FL0005551-00Medicaid
FLBA649YMedicare PIN