Provider Demographics
NPI:1558354951
Name:MIECZKOWSKI, LAWRENCE E (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:E
Last Name:MIECZKOWSKI
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 1:3080 ACKERMAN BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-3658
Mailing Address - Country:US
Mailing Address - Phone:937-294-3228
Mailing Address - Fax:937-394-3250
Practice Address - Street 1:3080 ACKERMAN BLVD STE 220
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-3658
Practice Address - Country:US
Practice Address - Phone:937-294-3228
Practice Address - Fax:937-294-3250
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH35-05-2076174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0603574Medicaid
OH000000020506OtherANTHEM
OHE00311469434OtherAETNA
OH04-20157OtherUNITEDHEALTHCARE
OH0634819OtherAETNA LIFE INSURANCE CO
OH0634819OtherAETNA LIFE INSURANCE CO
OHA16156Medicare UPIN