Healthcare Provider Details

I. General information

NPI: 1558354951
Provider Name (Legal Business Name): LAWRENCE E MIECZKOWSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3080 ACKERMAN BLVD STE 220
KETTERING OH
45429-3658
US

IV. Provider business mailing address

3080 ACKERMAN BLVD STE 220
KETTERING OH
45429-3658
US

V. Phone/Fax

Practice location:
  • Phone: 937-294-3228
  • Fax: 937-294-3250
Mailing address:
  • Phone: 937-294-3228
  • Fax: 937-394-3250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOH35-05-2076
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: