Provider Demographics
NPI:1710924675
Name:KIESZ, RADOSLAW STEFAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RADOSLAW
Middle Name:STEFAN
Last Name:KIESZ
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 1:18615 TUSCANY STONE
Mailing Address - Street 2:SUITE 170
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3486
Mailing Address - Country:US
Mailing Address - Phone:210-272-0098
Mailing Address - Fax:210-592-1462
Practice Address - Street 1:18615 TUSCANY STONE
Practice Address - Street 2:SUITE 170
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3489
Practice Address - Country:US
Practice Address - Phone:210-272-0649
Practice Address - Fax:210-592-1462
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7769207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161214501Medicaid
TX00758VMedicare ID - Type Unspecified
TX161214501Medicaid