Provider Demographics
NPI:1508173329
Name:KMIECIK, JOANNA LUCJA (MD)
Entity Type:Individual
Prefix:DR
First Name:JOANNA
Middle Name:LUCJA
Last Name:KMIECIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:213 N RACINE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1644
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:4848 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2718
Practice Address - Country:US
Practice Address - Phone:773-724-6200
Practice Address - Fax:773-866-8015
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036131178207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125058863OtherSTATE LICENSE
ILRES000Medicare UPIN