Healthcare Provider Details

I. General information

NPI: 1275890097
Provider Name (Legal Business Name): PAWEL MICHAL DUTKIEWICZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 ALDER ST
SOUTH BEND WA
98586
US

IV. Provider business mailing address

PO BOX 269
SOUTH BEND WA
98586-0269
US

V. Phone/Fax

Practice location:
  • Phone: 360-875-5579
  • Fax: 360-875-5235
Mailing address:
  • Phone: 360-875-5579
  • Fax: 334-566-3768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD34383
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60752511
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: