Healthcare Provider Details

I. General information

NPI: 1033100151
Provider Name (Legal Business Name): ROBERT WICKIEWICZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 RIVER ST
VALATIE NY
12184-9694
US

IV. Provider business mailing address

PO BOX 1123
LATHAM NY
12110-0079
US

V. Phone/Fax

Practice location:
  • Phone: 518-748-7736
  • Fax:
Mailing address:
  • Phone: 800-357-4829
  • Fax: 518-786-1293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number114150
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: