Provider Demographics
NPI:1659318129
Name:DZEDA, MICHAEL F (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:F
Last Name:DZEDA
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:PO BOX 12870
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19850-2870
Mailing Address - Country:US
Mailing Address - Phone:302-733-0374
Mailing Address - Fax:302-733-0854
Practice Address - Street 1:4701 OGLETOWN STANTON RD
Practice Address - Street 2:STE 1109
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2079
Practice Address - Country:US
Practice Address - Phone:302-623-4800
Practice Address - Fax:302-623-4850
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-00055952085R0001X
MDD00545952085R0001X
PAMD052967L2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD233604900Medicaid
DE0000935301Medicaid
DE920004715OtherRAILROAD MEDICARE
MD047M835EMedicare PIN
G10383Medicare UPIN
DE920004715OtherRAILROAD MEDICARE