Provider Demographics
NPI:1659362192
Name:SOSNOWSKI, JACEK T (MD)
Entity Type:Individual
Prefix:MR
First Name:JACEK
Middle Name:T
Last Name:SOSNOWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2805 N OAK ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602
Mailing Address - Country:US
Mailing Address - Phone:229-316-2990
Mailing Address - Fax:229-259-9547
Practice Address - Street 1:3580 SHERIDAN DR
Practice Address - Street 2:SUITE 150
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1645
Practice Address - Country:US
Practice Address - Phone:716-834-0100
Practice Address - Fax:716-834-1161
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2010-04-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY199804208800000X
GA058647208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA211307866AMedicaid
GAF06546Medicare UPIN
GA211307866AMedicaid
NYC24881Medicare ID - Type Unspecified