Provider Demographics
NPI:1699708636
Name:LUCIETTO-SIERADZKI, THERESE MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:THERESE
Middle Name:MARIE
Last Name:LUCIETTO-SIERADZKI
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:PO BOX 298
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-0298
Mailing Address - Country:US
Mailing Address - Phone:815-544-0087
Mailing Address - Fax:815-544-0088
Practice Address - Street 1:205 CADILLAC CT STE 7
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-1733
Practice Address - Country:US
Practice Address - Phone:815-544-0087
Practice Address - Fax:815-544-0088
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102862207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07132017OtherBLUE CROSS BLUE SHIELD ID
IL148976OtherMEDICARE-RIVERBEND ID
IL201772810001OtherMEDICAID RURAL HEALTH ID
IL036102862Medicaid
IL07132017OtherBLUE CROSS BLUE SHIELD ID
IL210988Medicare ID - Type Unspecified