Provider Demographics
NPI:1346385424
Name:GRZEGORCZYK, LAURETTA (MD)
Entity Type:Individual
Prefix:MS
First Name:LAURETTA
Middle Name:
Last Name:GRZEGORCZYK
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 1:2015 BATH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-4857
Mailing Address - Country:US
Mailing Address - Phone:718-266-3399
Mailing Address - Fax:718-266-2773
Practice Address - Street 1:2015 BATH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-4857
Practice Address - Country:US
Practice Address - Phone:718-266-3399
Practice Address - Fax:718-266-2773
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172740207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01839550Medicaid
NYF43073Medicare UPIN
NY01839550Medicaid