Provider Demographics
NPI:1962474163
Name:WESOLOWSKI, JEFFREY ROBERT (MD, MHSA)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ROBERT
Last Name:WESOLOWSKI
Suffix:
Gender:M
Credentials:MD, MHSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 FAWCETT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-1900
Mailing Address - Country:US
Mailing Address - Phone:253-761-4200
Mailing Address - Fax:253-761-4201
Practice Address - Street 1:1500 EAST MEDICAL CENTER DR
Practice Address - Street 2:B1 FLOOR UNIVERSITY HOSPITAL RECP C
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5030
Practice Address - Country:US
Practice Address - Phone:734-936-4566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010890732085R0202X, 2085N0700X
ORMD1807662085R0202X, 2085N0700X
WAMD607036352085N0700X, 2085R0202X
MDD00630472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2849OtherB/C B/S
MDJ062OtherB/C B/S
MDKA80OtherB/C B/S
MD407969800Medicaid
DEDD4343Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MDCD4495Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MDCN2566Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MD2849OtherB/C B/S
MDH94209Medicare UPIN
DE017983A20Medicare ID - Type UnspecifiedLOCALITY/JURIS. 02 DC/DE
MIH94209Medicare UPIN
MDJ062OtherB/C B/S
MD434LL658Medicare ID - Type UnspecifiedLOCALITY/JURIS. CODE 01