Provider Demographics
NPI:1235393448
Name:MICKIEWICZ-MARCINKOWSKA, EWA (MD)
Entity Type:Individual
Prefix:
First Name:EWA
Middle Name:
Last Name:MICKIEWICZ-MARCINKOWSKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1359 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-1016
Mailing Address - Country:US
Mailing Address - Phone:626-430-2900
Mailing Address - Fax:
Practice Address - Street 1:1359 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1016
Practice Address - Country:US
Practice Address - Phone:626-430-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4352822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102322768Medicaid
PA163019Medicare PIN