Provider Demographics
NPI:1487935870
Name:SISCOE, KIMBERLEY STASIA (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLEY
Middle Name:STASIA
Last Name:SISCOE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10298 E 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80238-4159
Mailing Address - Country:US
Mailing Address - Phone:347-749-0199
Mailing Address - Fax:
Practice Address - Street 1:8199 E 1ST AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80230-7163
Practice Address - Country:US
Practice Address - Phone:866-488-1863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2024-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00620402084P0800X, 2084P0804X
CAC1740332084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC392818Medicaid
SC392818Medicaid