Provider Demographics
NPI:1801239686
Name:DZIEDZIC, MICHAELLA (DO)
Entity type:Individual
Prefix:
First Name:MICHAELLA
Middle Name:
Last Name:DZIEDZIC
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MICHAELLA
Other - Middle Name:
Other - Last Name:JAMIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:139 SANDWICH ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2449
Mailing Address - Country:US
Mailing Address - Phone:508-746-5900
Mailing Address - Fax:508-747-2290
Practice Address - Street 1:139 SANDWICH ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2449
Practice Address - Country:US
Practice Address - Phone:508-746-5900
Practice Address - Fax:508-747-2290
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA267044208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics