Provider Demographics
NPI:1245201797
Name:CIEZKI, MARY ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY ELIZABETH
Middle Name:
Last Name:CIEZKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 S CASCADE AVE
Mailing Address - Street 2:140
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1624
Mailing Address - Country:US
Mailing Address - Phone:719-538-2950
Mailing Address - Fax:719-538-2996
Practice Address - Street 1:1633 MEDICAL CENTER PT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-5700
Practice Address - Country:US
Practice Address - Phone:719-475-9800
Practice Address - Fax:719-473-5436
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40061208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO61522848Medicaid
CO61522848Medicaid
447218Medicare ID - Type Unspecified