Provider Demographics
NPI:1548263130
Name:WIACEK, JAN (MD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:WIACEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 N OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-4640
Mailing Address - Country:US
Mailing Address - Phone:773-736-3131
Mailing Address - Fax:773-736-9416
Practice Address - Street 1:3204 N OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4640
Practice Address - Country:US
Practice Address - Phone:773-736-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088918207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088918Medicaid
IL036088918Medicaid
ILF29145Medicare UPIN