Provider Demographics
NPI:1093798621
Name:GARDYASZ, MIROSLAW (MD)
Entity Type:Individual
Prefix:MR
First Name:MIROSLAW
Middle Name:
Last Name:GARDYASZ
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 1:845 SIR THOMAS COURT
Mailing Address - Street 2:SUITE 7
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-4843
Mailing Address - Country:US
Mailing Address - Phone:717-652-7616
Mailing Address - Fax:717-909-3204
Practice Address - Street 1:845 SIR THOMAS COURT
Practice Address - Street 2:SUITE 7
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-4843
Practice Address - Country:US
Practice Address - Phone:717-652-7616
Practice Address - Fax:717-909-3204
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037373E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001616509Medicaid
PAB33615Medicare UPIN