Provider Demographics
NPI:1841292646
Name:ZIESKE, LARRY A (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:A
Last Name:ZIESKE
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 1:2211 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3711
Mailing Address - Country:US
Mailing Address - Phone:612-871-1144
Mailing Address - Fax:612-871-2012
Practice Address - Street 1:2211 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3711
Practice Address - Country:US
Practice Address - Phone:612-871-1144
Practice Address - Fax:612-871-2012
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37062207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN76D32ZIOtherBLUE SHIELD
MN1000010OtherMEDICA PRIMARY
MN1000133OtherMEDICA CHOICE
WI32466700OtherMEDICAID - WISCONSIN
MN639817100Medicaid
MN1016754OtherPREFERREDONE
MN768882OtherAMERICA'S PPO
MN768882OtherAMERICA'S PPO
MN1000010OtherMEDICA PRIMARY