Healthcare Provider Details

I. General information

NPI: 1255911145
Provider Name (Legal Business Name): JACEK BEDNARZ JR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 07/19/2024
Certification Date: 07/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S STATE ST STE 113
ABERDEEN SD
57401-4502
US

IV. Provider business mailing address

105 S STATE ST STE 113
ABERDEEN SD
57401-4502
US

V. Phone/Fax

Practice location:
  • Phone: 605-225-0378
  • Fax:
Mailing address:
  • Phone: 605-225-0378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15558
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: