Provider Demographics
NPI:1568454478
Name:KICZEK, CHRISTOPHER P (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:P
Last Name:KICZEK
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:PO BOX 567
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-0567
Mailing Address - Country:US
Mailing Address - Phone:216-464-5160
Mailing Address - Fax:216-464-5982
Practice Address - Street 1:2174 WARRENSVILLE CENTER RD
Practice Address - Street 2:
Practice Address - City:UNIVERSITY HTS
Practice Address - State:OH
Practice Address - Zip Code:44118-3125
Practice Address - Country:US
Practice Address - Phone:216-381-9000
Practice Address - Fax:216-381-2151
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35057943207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHE91449Medicare UPIN