Provider Demographics
NPI:1629217914
Name:DEWERA-MOCZERNIUK, ALICJA (MD)
Entity Type:Individual
Prefix:DR
First Name:ALICJA
Middle Name:
Last Name:DEWERA-MOCZERNIUK
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 1:2081 MILL PLAIN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-3062
Mailing Address - Country:US
Mailing Address - Phone:203-292-3078
Mailing Address - Fax:
Practice Address - Street 1:4699 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1830
Practice Address - Country:US
Practice Address - Phone:203-452-8322
Practice Address - Fax:203-371-7198
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT050411208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008036404Medicaid