Provider Demographics
NPI:1174859284
Name:NIEDZWIECKI, MATTHEW J (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:NIEDZWIECKI
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 1:345 BLACKSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4800
Mailing Address - Country:US
Mailing Address - Phone:401-455-6314
Mailing Address - Fax:
Practice Address - Street 1:500 W COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3661
Practice Address - Country:US
Practice Address - Phone:281-836-4735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA105641002084P0800X
NC2017-012792084P0800X
NH227842084P0800X
WAMD607496572084P0800X
CAC1569722084P0800X
TXV81562084P0800X
IL036.1305262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry