Provider Demographics
NPI:1497026314
Name:WIETRZYKOWSKI, RAYMOND LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:LOUIS
Last Name:WIETRZYKOWSKI
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 1:5739 N MCVICKER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6104
Mailing Address - Country:US
Mailing Address - Phone:773-930-3779
Mailing Address - Fax:
Practice Address - Street 1:5739 N MCVICKER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-6104
Practice Address - Country:US
Practice Address - Phone:773-930-3779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-24
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.045785207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology