Provider Demographics
NPI:1255490876
Name:KIESCHNICK, MEREDITH JANE (MD)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:JANE
Last Name:KIESCHNICK
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 1:2433 COFFEE LANE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472
Mailing Address - Country:US
Mailing Address - Phone:707-484-7944
Mailing Address - Fax:707-578-8037
Practice Address - Street 1:962 SEBASTOPOL RD
Practice Address - Street 2:ROSELAND CLINIC
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407
Practice Address - Country:US
Practice Address - Phone:707-578-2005
Practice Address - Fax:707-578-8037
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60980208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F27786Medicare UPIN