Healthcare Provider Details

I. General information

NPI: 1053359158
Provider Name (Legal Business Name): CIELO MARIE MACA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 11/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N MAIN ST
MOUNT VERNON MO
65712-1004
US

IV. Provider business mailing address

6250 CREEKSEDGE DR
OZARK MO
65721-6613
US

V. Phone/Fax

Practice location:
  • Phone: 417-461-5215
  • Fax: 417-461-5729
Mailing address:
  • Phone: 417-631-8605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number37314
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2006007765
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number015849
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: