Provider Demographics
NPI:1578632147
Name:NIEDZWIECKI, GERALD A (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:A
Last Name:NIEDZWIECKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2730 N MCMULLEN BOOTH RD
Mailing Address - Street 2:STE 100
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-3302
Mailing Address - Country:US
Mailing Address - Phone:727-791-7300
Mailing Address - Fax:727-723-9010
Practice Address - Street 1:2730 N MCMULLEN BOOTH RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-3325
Practice Address - Country:US
Practice Address - Phone:727-791-7300
Practice Address - Fax:727-723-9010
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00706492085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250195300Medicaid
FL4595565OtherAETNA PPO
FL1600774OtherUNITED HEALTHCARE
FL2648373OtherAETNA HMO
FL31439OtherBLUE CROSS BLUE SHIELD
FL4595565OtherAETNA PPO
FL1600774OtherUNITED HEALTHCARE