Provider Demographics
NPI:1356633598
Name:MAKUCHOWSKI, SIMON MATTHEW (IDC)
Entity Type:Individual
Prefix:MR
First Name:SIMON
Middle Name:MATTHEW
Last Name:MAKUCHOWSKI
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 OAKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GALES FERRY
Mailing Address - State:CT
Mailing Address - Zip Code:06335-1111
Mailing Address - Country:US
Mailing Address - Phone:609-731-5613
Mailing Address - Fax:
Practice Address - Street 1:4 OAKRIDGE DR
Practice Address - Street 2:
Practice Address - City:GALES FERRY
Practice Address - State:CT
Practice Address - Zip Code:06335-1111
Practice Address - Country:US
Practice Address - Phone:609-731-5613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-06
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman