Provider Demographics
NPI:1982317228
Name:KOLODZIEJCZYK, IDA
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:KOLODZIEJCZYK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 SW CHANDLER AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3208
Mailing Address - Country:US
Mailing Address - Phone:541-797-3052
Mailing Address - Fax:
Practice Address - Street 1:352 E HOOD AVE STE D
Practice Address - Street 2:
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759-1619
Practice Address - Country:US
Practice Address - Phone:541-904-4427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR64740208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR64740OtherDPT