Provider Demographics
NPI:1861462327
Name:CIESIELSKI, MATT (DO)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:CIESIELSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4666
Mailing Address - Country:US
Mailing Address - Phone:269-324-8950
Mailing Address - Fax:269-324-2134
Practice Address - Street 1:3300 W CENTRE AVE
Practice Address - Street 2:BRONSON FAMILY PRACTICE PORTAGE
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4666
Practice Address - Country:US
Practice Address - Phone:269-324-8950
Practice Address - Fax:269-324-2134
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICC3543OtherRAILROAD MEDICARE
MI4720485Medicaid
MIM20520033Medicare PIN
MI4720485Medicaid