Basic Information
| Provider Information | |||||||||
| NPI: | 1194083386 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIECZKOWSKI | ||||||||
| FirstName: | BRIDGET | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OLIVERI | ||||||||
| OtherFirstName: | BRIDGET | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 375 ALLENS AVE | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029055010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017802511 | ||||||||
| FaxNumber: | 4017802565 | ||||||||
| Practice Location | |||||||||
| Address1: | 239 CRANSTON ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029072406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014440580 | ||||||||
| FaxNumber: | 4014440428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2012 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 17125 | NH | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 285507 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD17889 | RI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.