Healthcare Provider Details

I. General information

NPI: 1780710038
Provider Name (Legal Business Name): J MICHAEL DZUBA M.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 N WASHINGTON ST
WILMINGTON DE
19801-1509
US

IV. Provider business mailing address

635 W SEDGWICK ST
PHILADELPHIA PA
19119-3442
US

V. Phone/Fax

Practice location:
  • Phone: 302-655-7110
  • Fax: 302-655-6185
Mailing address:
  • Phone: 215-849-2747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberQ1-0000120
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: