Provider Demographics
NPI:1306827696
Name:TKACZUK, EDMUND PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:PAUL
Last Name:TKACZUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7675 COLONIAL BEACH RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-3206
Mailing Address - Country:US
Mailing Address - Phone:443-537-3299
Mailing Address - Fax:410-360-4699
Practice Address - Street 1:7675 COLONIAL BEACH RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-3206
Practice Address - Country:US
Practice Address - Phone:443-537-3299
Practice Address - Fax:410-360-4699
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD34951207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD477971100Medicaid
MD477971100Medicaid