Provider Demographics
NPI:1316990849
Name:FIESER, CARL W (MD)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:W
Last Name:FIESER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 1ST AVE
Mailing Address - Street 2:STE A
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-2623
Mailing Address - Country:US
Mailing Address - Phone:620-225-1033
Mailing Address - Fax:620-227-8491
Practice Address - Street 1:2004 1ST AVE
Practice Address - Street 2:STE A
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-2623
Practice Address - Country:US
Practice Address - Phone:620-225-1033
Practice Address - Fax:620-227-8491
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-161182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100204750BMedicaid
OK200487030AMedicaid
CO91161182Medicaid
KSKA1172003OtherMEDICARE
COCO40688OtherMEDICARE COLORADO
CO6750056Medicaid
KSKA1173003OtherMEDICARE
KSB68448Medicare UPIN
OK200487030AMedicaid
CO91161182Medicaid