Provider Demographics
NPI:1578676243
Name:KIESEL, ERIN (DO)
Entity Type:Individual
Prefix:DR
First Name:ERIN
Middle Name:
Last Name:KIESEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:
Other - Last Name:BRADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1700 MCHENRY VILLAGE WAY STE 2
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4341
Mailing Address - Country:US
Mailing Address - Phone:209-549-1057
Mailing Address - Fax:209-549-9827
Practice Address - Street 1:1700 MCHENRY VILLAGE WAY STE 2
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4341
Practice Address - Country:US
Practice Address - Phone:209-549-1057
Practice Address - Fax:209-549-1057
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7197207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G98580Medicare UPIN
020A71971Medicare ID - Type UnspecifiedMCR INDIVIDUAL