Provider Demographics
NPI:1730131723
Name:KANIECKI, VIDA S (MD)
Entity Type:Individual
Prefix:DR
First Name:VIDA
Middle Name:S
Last Name:KANIECKI
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 1:6505 MARKET ST BLDG A1
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-3457
Mailing Address - Country:US
Mailing Address - Phone:330-746-8040
Mailing Address - Fax:330-746-8025
Practice Address - Street 1:6505 MARKET ST BLDG A1
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-3457
Practice Address - Country:US
Practice Address - Phone:330-746-8040
Practice Address - Fax:330-746-8025
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.134780208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012772440001Medicaid
PA198726H87OtherMEDICARE PTAN
1730131723OtherNPI