Provider Demographics
NPI:1518050756
Name:NIEDZWIECKI, COLLEEN (MD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:NIEDZWIECKI
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:PO BOX 862810
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-2810
Mailing Address - Country:US
Mailing Address - Phone:352-867-8898
Mailing Address - Fax:352-732-6282
Practice Address - Street 1:7171 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2630
Practice Address - Country:US
Practice Address - Phone:352-867-8898
Practice Address - Fax:352-732-6282
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68554207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378855500Medicaid
FL050083487OtherRAILROAD MEDICARE
FL27440OtherBLUE CROSS BLUE SHIELD
FL378855500Medicaid
FLG11216Medicare UPIN