Provider Demographics
NPI:1225038508
Name:GRZYBOWSKI, JACEK (MD)
Entity Type:Individual
Prefix:
First Name:JACEK
Middle Name:
Last Name:GRZYBOWSKI
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 1:812 N WOOD AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-4058
Mailing Address - Country:US
Mailing Address - Phone:908-587-9611
Mailing Address - Fax:908-587-9622
Practice Address - Street 1:812 N WOOD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-4058
Practice Address - Country:US
Practice Address - Phone:908-587-9611
Practice Address - Fax:908-587-9622
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07813200208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0059862Medicaid
NJ0059862Medicaid