Provider Demographics
NPI:1457351892
Name:WIECKOWSKI, PAUL J (DPM)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:WIECKOWSKI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PIKE ST
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-3919
Mailing Address - Country:US
Mailing Address - Phone:304-723-1797
Mailing Address - Fax:304-723-1755
Practice Address - Street 1:101 PIKE ST
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-3919
Practice Address - Country:US
Practice Address - Phone:304-723-1797
Practice Address - Fax:304-723-1755
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003459L213ES0103X
WV259213ES0103X
OH36003334W213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0099632000Medicaid
WV0099632000Medicaid
WVU02248Medicare UPIN
OH0707781Medicare ID - Type Unspecified
WV0707781Medicare ID - Type Unspecified