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General NPI Number Information
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NPI Number | 1144212879
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Entity Type | Individual
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Provider Name | WIESLAW K. PROKOP M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/18/2005
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Last Update Date | 06/20/2012
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Provider Practice Location Address
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Address Line | 15 PRESIDENTIAL BLVD SUITE 100
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City | BALA CYNWYD
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State | PA
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Zip | 19004-1000
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Country | US
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Telephone | 610-795-7366
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Fax | 610-664-4749
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Provider Business Mailing Address
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Address Line | PO BOX 237
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City | WYNNEWOOD
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State | PA
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Zip | 19096-0237
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Country | US
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Telephone | 610-795-7366
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Fax | 610-664-4749
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number | MD419479
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License Number State | PA
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