Provider Demographics
NPI:1467436733
Name:MATCZUK, AGNIESZKA (MD)
Entity Type:Individual
Prefix:
First Name:AGNIESZKA
Middle Name:
Last Name:MATCZUK
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 1:148 EAST AVE
Mailing Address - Street 2:SUITE 3G
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-5721
Mailing Address - Country:US
Mailing Address - Phone:203-838-4034
Mailing Address - Fax:203-853-6361
Practice Address - Street 1:148 EAST AVE
Practice Address - Street 2:SUITE 3G
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-5721
Practice Address - Country:US
Practice Address - Phone:203-838-4034
Practice Address - Fax:203-853-6361
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038563207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001385633Medicaid
H85672Medicare UPIN
CT001385633Medicaid