Provider Demographics
NPI:1053329094
Name:STANISLAV, ANDREW CHRISTIAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:CHRISTIAN
Last Name:STANISLAV
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 1:2725 S 144TH ST STE 212
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5253
Mailing Address - Country:US
Mailing Address - Phone:402-609-3000
Mailing Address - Fax:402-609-3808
Practice Address - Street 1:1260 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-5245
Practice Address - Country:US
Practice Address - Phone:712-396-4020
Practice Address - Fax:712-396-4025
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00681213E00000X, 213ES0103X
NE305213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1185355Medicaid
IA0429761Medicaid
IA19838Medicare ID - Type Unspecified
IA0429761Medicaid
IA1185355Medicaid