Provider Demographics
NPI:1881659282
Name:KWIATKOWSKI, TEREASE E (MD)
Entity Type:Individual
Prefix:
First Name:TEREASE
Middle Name:E
Last Name:KWIATKOWSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:150 N SYKES CREEK PKWY
Mailing Address - Street 2:#300
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3488
Mailing Address - Country:US
Mailing Address - Phone:321-449-4168
Mailing Address - Fax:321-449-4164
Practice Address - Street 1:255 FORTENBERRY RD
Practice Address - Street 2:A-1
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3601
Practice Address - Country:US
Practice Address - Phone:321-459-1192
Practice Address - Fax:321-459-2304
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME76969207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255238801Medicaid
F87734Medicare UPIN
FL255238801Medicaid