Provider Demographics
NPI:1366621476
Name:CESKO FAMILY PRACTICE PC
Entity type:Organization
Organization Name:CESKO FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:CESKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-324-3667
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301-0040
Mailing Address - Country:US
Mailing Address - Phone:307-324-3667
Mailing Address - Fax:307-324-5591
Practice Address - Street 1:819 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:RAWLINS
Practice Address - State:WY
Practice Address - Zip Code:82301-5462
Practice Address - Country:US
Practice Address - Phone:307-324-3667
Practice Address - Fax:307-324-5591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5910A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY112705500Medicaid
WYDD4463OtherPALMETTO ID
WYW20370Medicare PIN