Provider Demographics
NPI:1679537054
Name:NIEZGODA, JEFFREY A (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:NIEZGODA
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 1:2500 W LAYTON AVE
Mailing Address - Street 2:SUITE 30
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-5420
Mailing Address - Country:US
Mailing Address - Phone:414-269-5336
Mailing Address - Fax:
Practice Address - Street 1:2500 W LAYTON AVE
Practice Address - Street 2:STE 30
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-5436
Practice Address - Country:US
Practice Address - Phone:414-269-5336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40360-020207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32478300Medicaid
WI000173945Medicare ID - Type Unspecified
WIG22706Medicare UPIN