Provider Demographics
NPI:1972028421
Name:NIEDZIELAK, TIMOTHY RAYMOND (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:RAYMOND
Last Name:NIEDZIELAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 E RIVERSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-2300
Mailing Address - Country:US
Mailing Address - Phone:815-971-7000
Mailing Address - Fax:815-968-7830
Practice Address - Street 1:8201 E RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-2300
Practice Address - Country:US
Practice Address - Phone:815-971-7000
Practice Address - Fax:815-968-7830
Is Sole Proprietor?:No
Enumeration Date:2017-08-06
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5665207X00000X, 390200000X
MO2022018519207X00000X, 207XX0801X
IL036165587207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program