Healthcare Provider Details

I. General information

NPI: 1073900270
Provider Name (Legal Business Name): JOANNA GRZADZIEL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2015
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date: 09/14/2016
Reactivation Date: 05/01/2017

III. Provider practice location address

5 S CENTRE AVE STE A3
LEESPORT PA
19533-8661
US

IV. Provider business mailing address

5 S CENTRE AVE STE A3
LEESPORT PA
19533-8661
US

V. Phone/Fax

Practice location:
  • Phone: 610-926-5707
  • Fax: 610-926-8352
Mailing address:
  • Phone: 610-926-5707
  • Fax: 610-926-8352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS020821
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: