Provider Demographics
NPI:1467794446
Name:KICZEK, MATTHEW PAUL (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:PAUL
Last Name:KICZEK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9910 FRANKLIN SQUARE DR # 2110
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4902
Mailing Address - Country:US
Mailing Address - Phone:410-933-6421
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287
Practice Address - Country:US
Practice Address - Phone:410-955-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-18
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH872032085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH87203OtherLICENSE