Basic Information
| Provider Information | |||||||||
| NPI: | 1639196421 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PIWKO | ||||||||
| FirstName: | FREDERICK | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3805 LOCKPORT OLCOTT RD | ||||||||
| Address2: | |||||||||
| City: | LOCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140941128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164394248 | ||||||||
| FaxNumber: | 7164394838 | ||||||||
| Practice Location | |||||||||
| Address1: | 3805 LOCKPORT OLCOTT RD | ||||||||
| Address2: | |||||||||
| City: | LOCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140941128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164394248 | ||||||||
| FaxNumber: | 7164394838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 05/09/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 213857 1 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080145749 | 01 | NY | PALMETTO GBA MEDICARE RAILROAD | OTHER | 5999046 | 01 | GHI | OTHER | 0110742 | 01 | NY | INDEPENDENT HEALTH | OTHER | 00020529401 | 01 | UNWIRA | OTHER | 000525755001 | 01 | NY | BC/BS OF WESTERN NEW YROK | OTHER | 01956481 | 05 | NY | MEDICAID |