Provider Demographics
NPI:1790715746
Name:MLODZIENSKI, ALAN JOSEPH (DPM)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:JOSEPH
Last Name:MLODZIENSKI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 MARKET ST
Mailing Address - Street 2:MAB SUITE #111
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3153
Mailing Address - Country:US
Mailing Address - Phone:215-662-9563
Mailing Address - Fax:215-243-8818
Practice Address - Street 1:3801 MARKET ST
Practice Address - Street 2:MAB SUITE #111
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-3153
Practice Address - Country:US
Practice Address - Phone:215-662-9563
Practice Address - Fax:215-243-8818
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003011L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012155000010Medicaid
PA0012155000010Medicaid
483287M08Medicare PIN
PA4638080001Medicare NSC