Provider Demographics
NPI:1710126917
Name:KNIESOVA, MICHAELA (MD)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:KNIESOVA
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 1:350 W THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4409
Mailing Address - Country:US
Mailing Address - Phone:602-406-3538
Mailing Address - Fax:
Practice Address - Street 1:9059 W LAKE PLEASANT PKWY
Practice Address - Street 2:#E-540
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-8336
Practice Address - Country:US
Practice Address - Phone:623-322-3380
Practice Address - Fax:623-322-4399
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43390208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ545558Medicaid