Provider Demographics
NPI:1740246701
Name:WIECZOREK, STEPHEN M (DPM)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:M
Last Name:WIECZOREK
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 1:3263 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16504-1159
Mailing Address - Country:US
Mailing Address - Phone:814-456-7862
Mailing Address - Fax:814-452-1803
Practice Address - Street 1:3263 PINE AVE
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16504-1159
Practice Address - Country:US
Practice Address - Phone:814-456-7862
Practice Address - Fax:814-452-1803
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2013-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002919L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010471550002Medicaid
PA168427Medicare ID - Type Unspecified
PAT29876Medicare UPIN