Provider Demographics
NPI:1902860943
Name:JASKIEWICZ, RICHARD N (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:N
Last Name:JASKIEWICZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 S MARION AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5808
Mailing Address - Country:US
Mailing Address - Phone:386-755-3016
Mailing Address - Fax:386-719-3622
Practice Address - Street 1:619 S MARION AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5808
Practice Address - Country:US
Practice Address - Phone:386-755-3016
Practice Address - Fax:386-719-3622
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036479A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100098810Medicaid
152680CMedicare ID - Type Unspecified
IN100098810Medicaid