Healthcare Provider Details

I. General information

NPI: 1407847601
Provider Name (Legal Business Name): MARK ERNST GIESECKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463 SOUTH LAKE POWELL BLVD
PAGE AZ
86040-0790
US

IV. Provider business mailing address

420 W HAVASUPAI RD
FLAGSTAFF AZ
86001-1510
US

V. Phone/Fax

Practice location:
  • Phone: 928-645-5113
  • Fax: 928-645-3254
Mailing address:
  • Phone: 928-779-5419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number19591
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: