Provider Demographics
NPI:1962459701
Name:SZCZUPAK, WALDEMAR (MD)
Entity Type:Individual
Prefix:
First Name:WALDEMAR
Middle Name:
Last Name:SZCZUPAK
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 159
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-0159
Mailing Address - Country:US
Mailing Address - Phone:814-368-3123
Mailing Address - Fax:
Practice Address - Street 1:116 INTERSTATE PKWY
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-1036
Practice Address - Country:US
Practice Address - Phone:814-368-3123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036989E207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010906750001Medicare ID - Type Unspecified
PAD71182Medicare UPIN
PA115111D68Medicare ID - Type Unspecified