Healthcare Provider Details

I. General information

NPI: 1134210008
Provider Name (Legal Business Name): DR. MACIEJ J KIETURAKIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 SOUTH DR #7
MOUNTAIN VIEW CA
94040
US

IV. Provider business mailing address

305 SOUTH DR #7
MOUNTAIN VIEW CA
94040-4200
US

V. Phone/Fax

Practice location:
  • Phone: 650-938-6600
  • Fax: 650-938-6601
Mailing address:
  • Phone: 650-938-6600
  • Fax: 650-938-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA40880
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: