Provider Demographics
NPI:1336157080
Name:BIZJAK, RICHARD EDWARD (PAC)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:EDWARD
Last Name:BIZJAK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 BRIDLEWREATH WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-5586
Mailing Address - Country:US
Mailing Address - Phone:301-829-3435
Mailing Address - Fax:
Practice Address - Street 1:3414 OLANDWOOD CT
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1384
Practice Address - Country:US
Practice Address - Phone:301-774-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC00183363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
002555P53Medicare ID - Type Unspecified
MD570323Medicare UPIN