Provider Demographics
NPI:1053312785
Name:WALCZAK, KATHERINE L (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:L
Last Name:WALCZAK
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 1:1370 WASHINGTON PIKE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BRIDGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15017-2839
Mailing Address - Country:US
Mailing Address - Phone:412-221-0160
Mailing Address - Fax:412-221-0860
Practice Address - Street 1:1370 WASHINGTON PIKE
Practice Address - Street 2:SUITE 107
Practice Address - City:BRIDGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15017-2839
Practice Address - Country:US
Practice Address - Phone:412-221-0160
Practice Address - Fax:412-221-0860
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD051470L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014923950003Medicaid