Provider Demographics
NPI:1134145741
Name:WIERZBICKI, TIMOTHY J (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:WIERZBICKI
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 1:1211 DUNLAWTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-2913
Mailing Address - Country:US
Mailing Address - Phone:386-304-0111
Mailing Address - Fax:
Practice Address - Street 1:1211 DUNLAWTON AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-2913
Practice Address - Country:US
Practice Address - Phone:386-304-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME803342084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259058100Medicaid
FL130022355OtherMEDICARE RAILROAD
FL35363AMedicare ID - Type Unspecified
FL130022355OtherMEDICARE RAILROAD
35363XMedicare PIN