Provider Demographics
NPI:1033704226
Name:KIESOW, CALEB (MD)
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:
Last Name:KIESOW
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 1:9300 DEWITT LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT BELVOIR
Mailing Address - State:VA
Mailing Address - Zip Code:22060-5285
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8911 HARNESS WAY
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715
Practice Address - Country:US
Practice Address - Phone:920-740-0189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023007981207Q00000X
MO20230079891208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice