Provider Demographics
NPI:1932161049
Name:MISIEWICZ, MARIANNE J (DPM)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:J
Last Name:MISIEWICZ
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N KEENE ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6897
Mailing Address - Country:US
Mailing Address - Phone:573-443-2015
Mailing Address - Fax:573-449-5886
Practice Address - Street 1:305 N KEENE ST
Practice Address - Street 2:SUITE 209
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6897
Practice Address - Country:US
Practice Address - Phone:573-443-2015
Practice Address - Fax:573-449-5886
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003017378213E00000X, 213EP0504X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic Medicine
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU96480Medicare UPIN