Basic Information
| Provider Information | |||||||||
| NPI: | 1770775124 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DZIEDZIC | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 SEYMOUR ST. | ||||||||
| Address2: | CONKLILN BUILDING RM 114 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061025037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605451448 | ||||||||
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| Practice Location | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060321956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606792000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2007 | ||||||||
| LastUpdateDate: | 07/18/2008 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 046089 | CT | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.