Provider Demographics
NPI:1134210008
Name:KIETURAKIS, MACIEJ J
Entity type:Individual
Prefix:DR
First Name:MACIEJ
Middle Name:J
Last Name:KIETURAKIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 SOUTH DR
Mailing Address - Street 2:#7
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-4200
Mailing Address - Country:US
Mailing Address - Phone:650-938-6600
Mailing Address - Fax:650-938-6601
Practice Address - Street 1:305 SOUTH DR
Practice Address - Street 2:#7
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040
Practice Address - Country:US
Practice Address - Phone:650-938-6600
Practice Address - Fax:650-938-6601
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40880208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F06743Medicare UPIN
CA00A408800Medicare ID - Type Unspecified