Healthcare Provider Details

I. General information

NPI: 1629056957
Provider Name (Legal Business Name): WIESLAW MACHNOWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 10TH ST SE # LEVEL4
CEDAR RAPIDS IA
52403-1251
US

IV. Provider business mailing address

701 10TH ST SE
CEDAR RAPIDS IA
52403-1251
US

V. Phone/Fax

Practice location:
  • Phone: 319-861-7900
  • Fax: 319-861-7950
Mailing address:
  • Phone: 319-368-7900
  • Fax: 319-368-5690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29984
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1629056957
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier0109330
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: