Healthcare Provider Details

I. General information

NPI: 1831652908
Provider Name (Legal Business Name): JENNIFER N DZIWIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2019
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 EXECUTIVE DR STE 101
RALEIGH NC
27609-7491
US

IV. Provider business mailing address

3300 EXECUTIVE DR STE 101
RALEIGH NC
27609-7491
US

V. Phone/Fax

Practice location:
  • Phone: 919-862-5075
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2025-00726
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: