Basic Information
| Provider Information | |||||||||
| NPI: | 1245460419 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CZAJKOWSKI | ||||||||
| FirstName: | RADOSLAW | ||||||||
| MiddleName: | JAKUB | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7925 N WICKHAM RD STE A | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217517222 | ||||||||
| FaxNumber: | 3217516655 | ||||||||
| Practice Location | |||||||||
| Address1: | 1840 S WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | TITUSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213605577 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2009 | ||||||||
| LastUpdateDate: | 07/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME129106 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | ZFQ31815 | 01 | MEDICARE | OTHER | 733884 | 05 | AZ | MEDICAID |