Provider Demographics
NPI:1134190820
Name:NIEDRACH, WILLIAM L (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:L
Last Name:NIEDRACH
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 1:11 ROXBURY DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-3202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 ROXBURY DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-3202
Practice Address - Country:US
Practice Address - Phone:609-304-4337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05931400208800000X
PAMD479949208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0654743000OtherAMERIHEALTH
0465067OtherAETNA
745531AURMedicare ID - Type Unspecified
F61291Medicare UPIN