Provider Demographics
NPI:1417965369
Name:JEDRZYNSKI, MICHAEL CHARLES (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:JEDRZYNSKI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 MAIN ST #4
Mailing Address - Street 2:PO BOX 1163
Mailing Address - City:STURBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01566
Mailing Address - Country:US
Mailing Address - Phone:508-347-4900
Mailing Address - Fax:508-347-9339
Practice Address - Street 1:118 MAIN ST #4
Practice Address - Street 2:
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01566
Practice Address - Country:US
Practice Address - Phone:508-347-4900
Practice Address - Fax:508-347-9339
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2129213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
55385OtherFALLON
002129OtherTUFTS
Y71060OtherBCBS
MA0311081Medicaid
GALAXYOther862573
Y75066Medicare ID - Type Unspecified
55385OtherFALLON
GALAXYOther862573