Provider Demographics
NPI:1114920501
Name:KIELAK, MIROSLAW A (MD)
Entity Type:Individual
Prefix:
First Name:MIROSLAW
Middle Name:A
Last Name:KIELAK
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 1:406 N REO ST
Mailing Address - Street 2:STE 220
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-1028
Mailing Address - Country:US
Mailing Address - Phone:813-636-2000
Mailing Address - Fax:813-636-2050
Practice Address - Street 1:19048 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2434
Practice Address - Country:US
Practice Address - Phone:813-971-0077
Practice Address - Fax:813-971-8149
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65874207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL25335VMedicare ID - Type Unspecified
FLE17235Medicare UPIN