1457548364 NPI number — NICHOLAS PRZYSTAWSKI D.P.M.

Table of content: NICHOLAS PRZYSTAWSKI D.P.M. (NPI 1457548364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457548364 NPI number — NICHOLAS PRZYSTAWSKI D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRZYSTAWSKI
Provider First Name:
NICHOLAS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
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:
1457548364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 491334
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34749-1334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-360-1360
Provider Business Mailing Address Fax Number:
352-360-0686

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
913 E NORTH BLVD
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34748-5364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-360-1360
Provider Business Practice Location Address Fax Number:
352-360-0686
Provider Enumeration Date:
09/25/2007

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: 213ES0131X , with the licence number:  PO0002004 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 65384 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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