Provider Demographics
NPI:1437438710
Name:KUCHAREWICZ, JACEK M (MD)
Entity Type:Individual
Prefix:
First Name:JACEK
Middle Name:M
Last Name:KUCHAREWICZ
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 1:540 TRINITY LN N
Mailing Address - Street 2:#8412
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1278
Mailing Address - Country:US
Mailing Address - Phone:910-409-4207
Mailing Address - Fax:
Practice Address - Street 1:540 TRINITY LN N
Practice Address - Street 2:#8412
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-1278
Practice Address - Country:US
Practice Address - Phone:910-409-4207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTRAINING LICENSE390200000X
SC34101207R00000X
FLME126030208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC34101OtherSTATE LICENSE
FLME126030OtherFLORIDA MEDICAL LICENSE
VA0101255118OtherSTATE LICENSURE