Provider Demographics
NPI:1962572115
Name:JEDRZYNSKI, MICHAEL S (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:JEDRZYNSKI
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 1:6660 COYLE AVE #300
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608
Mailing Address - Country:US
Mailing Address - Phone:916-965-1115
Mailing Address - Fax:916-965-1155
Practice Address - Street 1:6660 COYLE AVE #300
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608
Practice Address - Country:US
Practice Address - Phone:916-965-1115
Practice Address - Fax:916-965-1155
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
G60011174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G600111Medicaid
CA00G600111Medicaid
CA00G600110Medicare ID - Type Unspecified