Healthcare Provider Details

I. General information

NPI: 1962459701
Provider Name (Legal Business Name): WALDEMAR SZCZUPAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 INTERSTATE PKWY
BRADFORD PA
16701-1036
US

IV. Provider business mailing address

PO BOX 159
BRADFORD PA
16701-0159
US

V. Phone/Fax

Practice location:
  • Phone: 814-368-3123
  • Fax:
Mailing address:
  • Phone: 814-368-3123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberMD036989E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: