Provider Demographics
NPI:1932699147
Name:DE FIESTA, MARK NACIANCENO
Entity Type:Individual
Prefix:
First Name:MARK NACIANCENO
Middle Name:
Last Name:DE FIESTA
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 1:105 ORCHARD HILLS DR APT 92
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-8281
Mailing Address - Country:US
Mailing Address - Phone:407-773-5523
Mailing Address - Fax:
Practice Address - Street 1:326 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150
Practice Address - Country:US
Practice Address - Phone:812-948-1311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOJH016M89073OtherBLUECROSSBLUESHIELD