Provider Demographics
NPI:1356393672
Name:WIECZOREK, J ERIC (MD)
Entity type:Individual
Prefix:
First Name:J
Middle Name:ERIC
Last Name:WIECZOREK
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 1:456 LOCUST STREET
Mailing Address - Street 2:PO BOX 199
Mailing Address - City:SIDMAN
Mailing Address - State:PA
Mailing Address - Zip Code:15955
Mailing Address - Country:US
Mailing Address - Phone:814-487-5721
Mailing Address - Fax:814-487-4781
Practice Address - Street 1:456 LOCUST STREET
Practice Address - Street 2:
Practice Address - City:SIDMAN
Practice Address - State:PA
Practice Address - Zip Code:15955
Practice Address - Country:US
Practice Address - Phone:814-487-5721
Practice Address - Fax:814-487-4781
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD027159E207Q00000X
PAMD 027159E207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010215060002Medicaid
PA0010215060002Medicaid
103060Medicare ID - Type Unspecified