Provider Demographics
NPI:1003925629
Name:MAVES, STEPHANIE M (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:MAVES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:M
Other - Last Name:NOVAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1777 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-2077
Mailing Address - Country:US
Mailing Address - Phone:262-284-3456
Mailing Address - Fax:
Practice Address - Street 1:1777 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2077
Practice Address - Country:US
Practice Address - Phone:262-284-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49574207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine