Provider Demographics
NPI:1417906405
Name:SIUDZINSKI, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SIUDZINSKI
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 1:2273 E GALA ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7289
Mailing Address - Country:US
Mailing Address - Phone:208-994-5700
Mailing Address - Fax:208-994-5700
Practice Address - Street 1:2273 E GALA ST
Practice Address - Street 2:SUITE 110
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7289
Practice Address - Country:US
Practice Address - Phone:208-994-5700
Practice Address - Fax:208-994-5700
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM-9339207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDI43707Medicare UPIN