Provider Demographics
NPI:1235518903
Name:MIECZKOWSKI, BRYCE (DO)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:
Last Name:MIECZKOWSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 12TH ST N STE 202
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2253
Mailing Address - Country:US
Mailing Address - Phone:320-258-3090
Mailing Address - Fax:320-258-3095
Practice Address - Street 1:3701 12TH ST N STE 202
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2253
Practice Address - Country:US
Practice Address - Phone:320-258-3090
Practice Address - Fax:320-258-3095
Is Sole Proprietor?:No
Enumeration Date:2015-05-27
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200D00X207L00000X
MN65396207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology