Provider Demographics
NPI:1639196421
Name:PIWKO, FREDERICK J (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:J
Last Name:PIWKO
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 1:3805 LOCKPORT OLCOTT RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-1128
Mailing Address - Country:US
Mailing Address - Phone:716-439-4248
Mailing Address - Fax:716-439-4838
Practice Address - Street 1:3805 LOCKPORT OLCOTT RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-1128
Practice Address - Country:US
Practice Address - Phone:716-439-4248
Practice Address - Fax:716-439-4838
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213857 1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY080145749OtherPALMETTO GBA MEDICARE RAILROAD
5999046OtherGHI
NY0110742OtherINDEPENDENT HEALTH
00020529401OtherUNWIRA
NY000525755001OtherBC/BS OF WESTERN NEW YROK
NY01956481Medicaid
NY0110742OtherINDEPENDENT HEALTH
NY01956481Medicaid