Provider Demographics
NPI:1902918774
Name:SIECZKA, ELIZABETH MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:MARIE
Last Name:SIECZKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1272 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2583
Mailing Address - Country:US
Mailing Address - Phone:631-663-4020
Mailing Address - Fax:631-663-4010
Practice Address - Street 1:630 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-6544
Practice Address - Country:US
Practice Address - Phone:212-439-1600
Practice Address - Fax:212-439-6269
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1986982086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH48830Medicare UPIN