Basic Information
| Provider Information | |||||||||
| NPI: | 1386611440 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DZIELAK | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 S WASHINGTON AVE STE 1000 | ||||||||
| Address2: | |||||||||
| City: | SCRANTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 185053814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703432383 | ||||||||
| FaxNumber: | 5703433923 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 S WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | JERMYN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184331121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702300019 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS004141L | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | OS004141L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000834808 | 05 | PA | MEDICAID |