Provider Demographics
NPI:1013027861
Name:PTAKOWSKI, GEORGE ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:ANTHONY
Last Name:PTAKOWSKI
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 1:1109 AUDUBON DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411
Mailing Address - Country:US
Mailing Address - Phone:570-576-4210
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 147
Practice Address - Street 2:
Practice Address - City:POCONO LAKE
Practice Address - State:PA
Practice Address - Zip Code:18347-0147
Practice Address - Country:US
Practice Address - Phone:570-646-6905
Practice Address - Fax:570-646-6009
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040378-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01158190Medicaid
PA01158190Medicaid
PA187471Medicare ID - Type Unspecified