Healthcare Provider Details

I. General information

NPI: 1518044239
Provider Name (Legal Business Name): WIESLAWA D DZIEDZIC-WISINSKI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WIESLAWA D WISINSKI MD

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8114 SANDPIPER CIRCLE #100
BALTIMORE MD
21236
US

IV. Provider business mailing address

8114 SANDPIPER CIRCLE #100
BALTIMORE MD
21236
US

V. Phone/Fax

Practice location:
  • Phone: 410-933-8101
  • Fax: 410-933-8106
Mailing address:
  • Phone: 410-933-8101
  • Fax: 410-933-8106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0043818
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: