Provider Demographics
NPI:1477555969
Name:DANIELEWSKI, JERZY L (MD)
Entity Type:Individual
Prefix:
First Name:JERZY
Middle Name:L
Last Name:DANIELEWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GEORGE
Other - Middle Name:L
Other - Last Name:DANIELEWSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:142 BELLEVUE AVE
Mailing Address - Street 2:
Mailing Address - City:PENNDEL
Mailing Address - State:PA
Mailing Address - Zip Code:19047-5256
Mailing Address - Country:US
Mailing Address - Phone:215-757-4455
Mailing Address - Fax:215-757-1707
Practice Address - Street 1:142 BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:PENNDEL
Practice Address - State:PA
Practice Address - Zip Code:19047-5256
Practice Address - Country:US
Practice Address - Phone:215-757-4455
Practice Address - Fax:215-757-1707
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2013-05-15
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
PAMD034515L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0611025Medicaid
PAB37233Medicare UPIN
PA0611025Medicaid