=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063497824
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WALTER WIELKIEWICZ M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2005
-----------------------------------------------------
Last Update Date | 02/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 751 FOREST AVE STE 402
-----------------------------------------------------
City | ZANESVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43701-2878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-454-0196
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 860 BETHESDA DR
-----------------------------------------------------
City | ZANESVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43701-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-454-4651
-----------------------------------------------------
Fax | 740-454-4653
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 35052245W
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------