Healthcare Provider Details

I. General information

NPI: 1639623978
Provider Name (Legal Business Name): BRIAN MICHAEL WOJTKIELEWICZ D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

991 ROUTE 19 N STE B
WATERFORD PA
16441-9739
US

IV. Provider business mailing address

991 ROUTE 19 N STE B
WATERFORD PA
16441-9739
US

V. Phone/Fax

Practice location:
  • Phone: 814-877-8790
  • Fax: 814-796-4238
Mailing address:
  • Phone: 814-877-8790
  • Fax: 814-796-4238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number306965
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS019020
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: