Provider Demographics
NPI:1275890097
Name:DUTKIEWICZ, PAWEL MICHAL (MD)
Entity Type:Individual
Prefix:MR
First Name:PAWEL
Middle Name:MICHAL
Last Name:DUTKIEWICZ
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:PO BOX 269
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:WA
Mailing Address - Zip Code:98586-0269
Mailing Address - Country:US
Mailing Address - Phone:360-875-5579
Mailing Address - Fax:334-566-3768
Practice Address - Street 1:826 ALDER ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:WA
Practice Address - Zip Code:98586
Practice Address - Country:US
Practice Address - Phone:360-875-5579
Practice Address - Fax:360-875-5235
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD34383208D00000X
WAMD60752511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice