Provider Demographics
NPI:1215212691
Name:WIECZOREK, NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:WIECZOREK
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 1:303 PERIMETER CTR N
Mailing Address - Street 2:STE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30346-3401
Mailing Address - Country:US
Mailing Address - Phone:704-626-2505
Mailing Address - Fax:704-626-2505
Practice Address - Street 1:6000 FAIRVIEW RD STE 1200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-2252
Practice Address - Country:US
Practice Address - Phone:704-626-2505
Practice Address - Fax:704-626-2505
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57020097207R00000X
NC183488208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20-38651OtherCSR
NC1215212691Medicaid
SC20-38651OtherCSR
NCFW5424774OtherDEA
NCNC0022D340Medicare PIN