Healthcare Provider Details

I. General information

NPI: 1366621476
Provider Name (Legal Business Name): CESKO FAMILY PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 11/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 W MAPLE ST
RAWLINS WY
82301-5462
US

IV. Provider business mailing address

PO BOX 40
RAWLINS WY
82301-0040
US

V. Phone/Fax

Practice location:
  • Phone: 307-324-3667
  • Fax: 307-324-5591
Mailing address:
  • Phone: 307-324-3667
  • Fax: 307-324-5591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5910A
License Number StateWY

VIII. Authorized Official

Name: DAVID R CESKO
Title or Position: OWNER
Credential: MD
Phone: 307-324-3667