Provider Demographics
NPI:1790792034
Name:PIETRZAK, NICHOLAS A II (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:A
Last Name:PIETRZAK
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3951 RIDGE AVE
Mailing Address - Street 2:STE B
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-5051
Mailing Address - Country:US
Mailing Address - Phone:478-757-1934
Mailing Address - Fax:478-757-1596
Practice Address - Street 1:3951 RIDGE AVE
Practice Address - Street 2:STE B
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5051
Practice Address - Country:US
Practice Address - Phone:478-757-1934
Practice Address - Fax:478-757-1596
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2012-02-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA044308207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00834413DMedicaid
GAH00697Medicare UPIN
GA00834413DMedicaid