Healthcare Provider Details

I. General information

NPI: 1417185240
Provider Name (Legal Business Name): JACOB E BIESZCZAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 03/07/2023
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5757 PARK CENTER CT.
TOLEDO OH
43615
US

IV. Provider business mailing address

5757 PARK CENTER CT.
TOLEDO OH
43615
US

V. Phone/Fax

Practice location:
  • Phone: 419-474-4064
  • Fax: 419-472-2772
Mailing address:
  • Phone: 419-474-4064
  • Fax: 419-472-2772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number121217
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: