Provider Demographics
NPI:1902953433
Name:DIACZYK, ANDREW J (DO)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:J
Last Name:DIACZYK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4887 34TH ST S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-4509
Mailing Address - Country:US
Mailing Address - Phone:727-864-4047
Mailing Address - Fax:727-864-0060
Practice Address - Street 1:4887 34TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-4509
Practice Address - Country:US
Practice Address - Phone:727-864-4047
Practice Address - Fax:727-864-0060
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 1348152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20123Medicare ID - Type Unspecified