Healthcare Provider Details

I. General information

NPI: 1225038508
Provider Name (Legal Business Name): JACEK GRZYBOWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 N WOOD AVE SUITE 201
LINDEN NJ
07036-4058
US

IV. Provider business mailing address

812 N WOOD AVE SUITE 201
LINDEN NJ
07036-4058
US

V. Phone/Fax

Practice location:
  • Phone: 908-587-9611
  • Fax: 908-587-9622
Mailing address:
  • Phone: 908-587-9611
  • Fax: 908-587-9622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA07813200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: