Provider Demographics
NPI:1225092075
Name:WIECZOREK, TAD J (MD)
Entity Type:Individual
Prefix:DR
First Name:TAD
Middle Name:J
Last Name:WIECZOREK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1153 CENTRE ST
Mailing Address - Street 2:DEPT OF PATHOLOGY, FAULKNER HOSPITAL
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3446
Mailing Address - Country:US
Mailing Address - Phone:617-983-7663
Mailing Address - Fax:617-983-7736
Practice Address - Street 1:1153 CENTRE ST
Practice Address - Street 2:DEPT OF PATHOLOGY, FAULKNER HOSPITAL
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-983-7666
Practice Address - Fax:617-983-7736
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2010-12-09
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Provider Licenses
StateLicense IDTaxonomies
MA160676207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0145301Medicaid
MAA32536Medicare ID - Type Unspecified
MA0145301Medicaid