Provider Demographics
NPI:1659860872
Name:WIECKOWSKA, JOANNA (DO)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:WIECKOWSKA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776982
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6982
Mailing Address - Country:US
Mailing Address - Phone:800-494-5797
Mailing Address - Fax:
Practice Address - Street 1:1560 E SHERMAN BLVD
Practice Address - Street 2:STE 250
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1854
Practice Address - Country:US
Practice Address - Phone:231-672-6186
Practice Address - Fax:231-672-6181
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101023799207R00000X
MI5101028236207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine