Provider Demographics
NPI:1225105513
Name:IWANICKI, JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:IWANICKI
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 1:2792 OCEAN AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-4731
Mailing Address - Country:US
Mailing Address - Phone:833-635-2566
Mailing Address - Fax:833-635-2566
Practice Address - Street 1:2792 OCEAN AVE FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4731
Practice Address - Country:US
Practice Address - Phone:833-635-2566
Practice Address - Fax:833-635-2566
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157144207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A60835Medicare UPIN
JI016D1610Medicare ID - Type Unspecified
NYA60835Medicare UPIN