Provider Demographics
NPI:1912112384
Name:MAMCZAK, CHRISTIAAN NIKOLAJE (DO)
Entity type:Individual
Prefix:DR
First Name:CHRISTIAAN
Middle Name:NIKOLAJE
Last Name:MAMCZAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 7TH ST S STE 450
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4741
Mailing Address - Country:US
Mailing Address - Phone:727-527-5272
Mailing Address - Fax:727-522-7412
Practice Address - Street 1:603 7TH ST S STE 450
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4741
Practice Address - Country:US
Practice Address - Phone:727-527-5272
Practice Address - Fax:727-522-7412
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004231A207X00000X, 207XX0801X, 207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLO5607OtherMEDICARE
FL113496800Medicaid
FLO5607OtherMEDICARE
INP01340628OtherRR MEDICARE
IN236040223OtherMEDICARE PTAN
IN000000831457OtherBCBS BMG ORTHOPEDIC TRAUMA
FL113496800Medicaid
IN169380062OtherMEDICARE PTAN
IN247000020OtherMEDICARE PTAN