Provider Demographics
NPI:1043233166
Name:WALCZYK, JOHN STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:STEVEN
Last Name:WALCZYK
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 1:1165 NORTHERN BLVD
Mailing Address - Street 2:SUITE 405
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3048
Mailing Address - Country:US
Mailing Address - Phone:516-365-8030
Mailing Address - Fax:516-365-8058
Practice Address - Street 1:1165 NORTHERN BLVD
Practice Address - Street 2:SUITE 405
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3048
Practice Address - Country:US
Practice Address - Phone:516-365-8030
Practice Address - Fax:516-365-8058
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191586207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF81219Medicare UPIN
NY2K3881Medicare ID - Type Unspecified