Provider Demographics
NPI:1316986664
Name:SIEDLECKI, JOHN ALEXANDER (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ALEXANDER
Last Name:SIEDLECKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3742 WINTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-9230
Mailing Address - Country:US
Mailing Address - Phone:804-330-3335
Mailing Address - Fax:804-330-9205
Practice Address - Street 1:3742 WINTERFIELD RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-9238
Practice Address - Country:US
Practice Address - Phone:804-330-3335
Practice Address - Fax:804-330-9205
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054432207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA080125969OtherMEDICARE RAILROAD
VA080006515Medicare ID - Type Unspecified
VAG28320Medicare UPIN
0914020001Medicare NSC