Healthcare Provider Details

I. General information

NPI: 1952424301
Provider Name (Legal Business Name): NICHOLAS JOHN URBANCZYK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 12/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 UNION ST
LYNN MA
01901-1314
US

IV. Provider business mailing address

269 UNION ST
LYNN MA
01901-1314
US

V. Phone/Fax

Practice location:
  • Phone: 781-581-3900
  • Fax: 781-715-6232
Mailing address:
  • Phone: 781-581-3900
  • Fax: 781-715-6232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number5101016342
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number249578
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: