Provider Demographics
NPI:1144212879
Name:PROKOP, WIESLAW K (MD)
Entity Type:Individual
Prefix:DR
First Name:WIESLAW
Middle Name:K
Last Name:PROKOP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:WES
Other - Middle Name:
Other - Last Name:PROKOP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 237
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-0237
Mailing Address - Country:US
Mailing Address - Phone:610-795-7366
Mailing Address - Fax:610-664-4749
Practice Address - Street 1:15 PRESIDENTIAL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1000
Practice Address - Country:US
Practice Address - Phone:610-795-7366
Practice Address - Fax:610-664-4749
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD419479207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA19053230001Medicaid
PA062974Medicare ID - Type Unspecified
PA19053230001Medicaid