Basic Information
| Provider Information | |||||||||
| NPI: | 1255415352 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | KIZILISIK | ||||||||
| FirstName: | AYDIN | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6920 POINTE INVERNESS WAY STE 200 | ||||||||
| Address2: | MEDPARTNERS, ATTN: BARB COPELAND | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604793514 | ||||||||
| FaxNumber: | 2604793520 | ||||||||
| Practice Location | |||||||||
| Address1: | 7910 W JEFFERSON BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604356275 | ||||||||
| FaxNumber: | 2604356279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 12/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204F00000X | 01062836A | IN | Y | Allopathic & Osteopathic Physicians | Transplant Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200861790 | 05 | IN | MEDICAID |