Provider Demographics
NPI:1740360163
Name:PIENIAZEK, JOHN J (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:PIENIAZEK
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:BOX 497
Mailing Address - Street 2:INDIAN HEALTH SERVICE
Mailing Address - City:RED LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671
Mailing Address - Country:US
Mailing Address - Phone:218-679-3912
Mailing Address - Fax:218-679-0181
Practice Address - Street 1:HWY 1
Practice Address - Street 2:
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671
Practice Address - Country:US
Practice Address - Phone:218-679-3912
Practice Address - Fax:218-679-0181
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336-072015207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I20319Medicare UPIN
MN240206Medicare Oscar/Certification