Provider Demographics
NPI:1912946096
Name:NIESLUCHOWSKI, WITOLD S (MD)
Entity Type:Individual
Prefix:
First Name:WITOLD
Middle Name:S
Last Name:NIESLUCHOWSKI
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 1:206 JOE V. KNOX AVENUE
Mailing Address - Street 2:SUITE H
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8104
Mailing Address - Country:US
Mailing Address - Phone:424-488-3467
Mailing Address - Fax:704-661-1396
Practice Address - Street 1:206 JOE V. KNOX AVENUE
Practice Address - Street 2:SUITE H
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8104
Practice Address - Country:US
Practice Address - Phone:424-488-3467
Practice Address - Fax:704-661-1396
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40288174400000X
NC186439174400000X, 2086S0129X
NC00483202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No174400000XOther Service ProvidersSpecialist
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330005101OtherRR MEDICARE
CA77-0079544OtherBLUE CROSS
CAA88524Medicare UPIN
CAWA40288AMedicare PIN
CAGR0098310OtherMEDI-CAL
CAWA40288DMedicare PIN
CAZZZ08582ZOtherBLUE SHIELD