Provider Demographics
NPI:1881769776
Name:CZARNECKI, THOMAS NICHOLAS JR (DPM)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:NICHOLAS
Last Name:CZARNECKI
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:ATTN: CSMCP CLINIC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:262-250-7800
Mailing Address - Fax:
Practice Address - Street 1:N112W15415 MEQUON RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-3410
Practice Address - Country:US
Practice Address - Phone:262-250-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-23
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI025-519213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43205100Medicaid
WI43205100Medicaid
WI1002790001Medicare NSC
WIT61717Medicare UPIN
WI86500Medicare ID - Type UnspecifiedHARTFORD OFFICE