Provider Demographics
NPI:1740401538
Name:WIECKOWSKI, JAN MICHAL (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:JAN
Middle Name:MICHAL
Last Name:WIECKOWSKI
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:MICHAL
Other - Last Name:WIECKOWSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:4332 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-1147
Mailing Address - Country:US
Mailing Address - Phone:716-773-7927
Mailing Address - Fax:
Practice Address - Street 1:4332 E RIVER RD
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072-1147
Practice Address - Country:US
Practice Address - Phone:716-773-7927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123310261QA0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0006XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Fertility Facility