Provider Demographics
NPI:1518953041
Name:NIEMCZYK, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:NIEMCZYK
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 1:20325 N 51ST AVE
Mailing Address - Street 2:#102
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5674
Mailing Address - Country:US
Mailing Address - Phone:623-780-2300
Mailing Address - Fax:623-582-9666
Practice Address - Street 1:5171 CUB LAKE RD
Practice Address - Street 2:BLDG C STE 340
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7888
Practice Address - Country:US
Practice Address - Phone:928-537-0111
Practice Address - Fax:623-582-9666
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ34718208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2Z2716OtherHEALTHNET
AZ477100Medicaid
5135633OtherAETNA
674661OtherCIGNA
P00378324OtherRAILROAD MEDICARE
AZAZ0156450OtherBLUE CROSS BLUE SHIELD
674661OtherCIGNA
5135633OtherAETNA