Provider Demographics
NPI:1073547949
Name:STANLEY, JERREL L (MD)
Entity Type:Individual
Prefix:
First Name:JERREL
Middle Name:L
Last Name:STANLEY
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 1:3003 W GOOD HOPE ROAD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:N112 W 17975 MEQUON ROAD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022
Practice Address - Country:US
Practice Address - Phone:262-532-7600
Practice Address - Fax:262-532-7602
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22544207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00451316OtherRR MEDICARE
WI30387500Medicaid
B56828Medicare UPIN
WI30387500Medicaid
WI46236-0129Medicare PIN