Provider Demographics
NPI:1184949216
Name:MIETELSKI, MEGAN (MD)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:MIETELSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MARTIN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6564
Mailing Address - Country:US
Mailing Address - Phone:630-369-7700
Mailing Address - Fax:630-369-7705
Practice Address - Street 1:10 MARTIN AVE STE 100
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6564
Practice Address - Country:US
Practice Address - Phone:630-369-7700
Practice Address - Fax:630-369-7705
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073767A207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036142172Medicaid
ILF400368541OtherMEDICARE PTAN