Provider Demographics
NPI:1407847601
Name:GIESECKE, MARK ERNST (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ERNST
Last Name:GIESECKE
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 1:420 W HAVASUPAI RD
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1510
Mailing Address - Country:US
Mailing Address - Phone:928-779-5419
Mailing Address - Fax:
Practice Address - Street 1:463 SOUTH LAKE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-0790
Practice Address - Country:US
Practice Address - Phone:928-645-5113
Practice Address - Fax:928-645-3254
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ195912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
B36822Medicare UPIN