1689666794 NPI number — DR. EDWARD N PRIKASZCZIKOW DPM

Table of content: DR. EDWARD N PRIKASZCZIKOW DPM (NPI 1689666794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689666794 NPI number — DR. EDWARD N PRIKASZCZIKOW DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRIKASZCZIKOW
Provider First Name:
EDWARD
Provider Middle Name:
N
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689666794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 MCKENZIE AVE
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
COUNCIL BLUFFS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51503-1002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-328-0297
Provider Business Mailing Address Fax Number:
712-328-2403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 MCKENZIE AVE
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51503-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-328-0297
Provider Business Practice Location Address Fax Number:
712-328-2403
Provider Enumeration Date:
08/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  368 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0004200 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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