1659362192 NPI number — MR. JACEK T SOSNOWSKI MD

Table of content: MR. JACEK T SOSNOWSKI MD (NPI 1659362192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659362192 NPI number — MR. JACEK T SOSNOWSKI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOSNOWSKI
Provider First Name:
JACEK
Provider Middle Name:
T
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1659362192
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2805 N OAK ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
VALDOSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-316-2990
Provider Business Mailing Address Fax Number:
229-259-9547

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3580 SHERIDAN DR
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
AMHERST
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14226-1645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-834-0100
Provider Business Practice Location Address Fax Number:
716-834-1161
Provider Enumeration Date:
11/03/2005

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: 208800000X , with the licence number:  199804 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 058647 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 211307866A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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