Provider Demographics
NPI:1073719746
Name:DZIEDZIC, THOMAS SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:SCOTT
Last Name:DZIEDZIC
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 1:1025 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7354
Mailing Address - Country:US
Mailing Address - Phone:910-762-3882
Mailing Address - Fax:
Practice Address - Street 1:1025 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401
Practice Address - Country:US
Practice Address - Phone:910-762-3882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-011422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ035729Medicaid
MD225940ZHVTMedicare PIN
DC056595900Medicaid
VA1073719746Medicaid
MD225940ZHVTMedicare PIN