Provider Demographics
NPI:1679735104
Name:KSIAZEK, JEFFREY MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:KSIAZEK
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 1:25 N WINFIELD ROAD #519
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1222
Mailing Address - Country:US
Mailing Address - Phone:630-668-2180
Mailing Address - Fax:
Practice Address - Street 1:25 N WINFIELD ROAD
Practice Address - Street 2:#519
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190
Practice Address - Country:US
Practice Address - Phone:630-668-2180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036132930207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology