Provider Demographics
NPI:1932101912
Name:MIDURA, MIECZYSLAW (MD)
Entity Type:Individual
Prefix:DR
First Name:MIECZYSLAW
Middle Name:
Last Name:MIDURA
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:PO BOX 32161
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06150-2161
Mailing Address - Country:US
Mailing Address - Phone:800-875-4886
Mailing Address - Fax:
Practice Address - Street 1:699 92ND ST
Practice Address - Street 2:VICTORY MEMORIAL HOSPITAL
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-3619
Practice Address - Country:US
Practice Address - Phone:718-567-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115274207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00802626Medicaid
NY00802626Medicaid
NYB16522Medicare UPIN