Provider Demographics
NPI:1073533402
Name:STASTNY, MARY JO (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:STASTNY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 TRI PARK WAY
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-1658
Mailing Address - Country:US
Mailing Address - Phone:920-831-7919
Mailing Address - Fax:920-831-7939
Practice Address - Street 1:10 TRI PARK WAY
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-1658
Practice Address - Country:US
Practice Address - Phone:920-831-7919
Practice Address - Fax:920-831-7939
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27088207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB56835Medicare UPIN