Provider Demographics
NPI:1093810095
Name:SIARKOWICZ, EDWARD CHARLES (DC)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:CHARLES
Last Name:SIARKOWICZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 E MOODY BLVD
Mailing Address - Street 2:#105
Mailing Address - City:BUNNELL
Mailing Address - State:FL
Mailing Address - Zip Code:32110-7709
Mailing Address - Country:US
Mailing Address - Phone:386-437-2012
Mailing Address - Fax:386-437-2191
Practice Address - Street 1:4750 E MOODY BLVD
Practice Address - Street 2:#105
Practice Address - City:BUNNELL
Practice Address - State:FL
Practice Address - Zip Code:32110-7709
Practice Address - Country:US
Practice Address - Phone:386-437-2012
Practice Address - Fax:386-437-2191
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6640111N00000X
NYX007478111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
22923ZMedicare ID - Type Unspecified
22923Medicare UPIN