Provider Demographics
NPI:1972703908
Name:KIESAU, CARTER DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:CARTER
Middle Name:DAVID
Last Name:KIESAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5096
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-5096
Mailing Address - Country:US
Mailing Address - Phone:360-733-2092
Mailing Address - Fax:360-733-4013
Practice Address - Street 1:3015 SQUALICUM PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1945
Practice Address - Country:US
Practice Address - Phone:360-733-2092
Practice Address - Fax:360-733-4013
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ80869207X00000X
NC2009-00916207X00000X
WAMD60125328207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8893183Medicaid
WA0261214OtherL&I AND CRIME VICTIMS
WA0169KIOtherREGENCE
WA1972703908Medicaid