Basic Information
| Provider Information | |||||||||
| NPI: | 1417185240 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BIESZCZAD | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5757 PARK CENTER CT. | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194744064 | ||||||||
| FaxNumber: | 4194722772 | ||||||||
| Practice Location | |||||||||
| Address1: | 5757 PARK CENTER CT. | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194744064 | ||||||||
| FaxNumber: | 4194722772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2009 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 121217 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 0075653 | 05 | OH | MEDICAID | FB3117199 | 01 | OH | DEA | OTHER |