Provider Demographics
NPI:1003859240
Name:MUDRYJ, STEFAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:STEFAN
Middle Name:
Last Name:MUDRYJ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50848
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85076-0848
Mailing Address - Country:US
Mailing Address - Phone:480-235-5797
Mailing Address - Fax:480-629-5206
Practice Address - Street 1:16601 N 40TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3354
Practice Address - Country:US
Practice Address - Phone:480-235-5797
Practice Address - Fax:480-629-5206
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0493213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ465345Medicaid
AZ465345Medicaid
AZU68744Medicare UPIN