Provider Demographics
NPI:1821056540
Name:PIETA, JACEK HENRYK (MD)
Entity type:Individual
Prefix:
First Name:JACEK
Middle Name:HENRYK
Last Name:PIETA
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 1:311 9TH ST. N.
Mailing Address - Street 2:SUITE 304
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102
Mailing Address - Country:US
Mailing Address - Phone:239-624-8250
Mailing Address - Fax:239-624-8251
Practice Address - Street 1:1726 MEDICAL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-1426
Practice Address - Country:US
Practice Address - Phone:239-624-8250
Practice Address - Fax:239-624-8251
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME153904207RP1001X, 207R00000X, 207RC0200X
IL036087837207R00000X, 207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087837Medicaid
FL118420400Medicaid
IL02215074OtherBLUE SHIELD PROVIDER NUMB