Healthcare Provider Details

I. General information

NPI: 1679537054
Provider Name (Legal Business Name): JEFFREY A NIEZGODA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 09/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W LAYTON AVE STE 30
MILWAUKEE WI
53221-5436
US

IV. Provider business mailing address

2500 W LAYTON AVE SUITE 30
MILWAUKEE WI
53221-5420
US

V. Phone/Fax

Practice location:
  • Phone: 414-269-5336
  • Fax:
Mailing address:
  • Phone: 414-269-5336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number40360-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: