Provider Demographics
NPI:1093084568
Name:J. JOHN STASIKOWSKI, MD PA
Entity Type:Organization
Organization Name:J. JOHN STASIKOWSKI, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACEK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:STASIKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:817-926-8002
Mailing Address - Street 1:1307 8TH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4137
Mailing Address - Country:US
Mailing Address - Phone:817-926-8002
Mailing Address - Fax:817-926-2315
Practice Address - Street 1:1307 8TH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4137
Practice Address - Country:US
Practice Address - Phone:817-926-8002
Practice Address - Fax:817-926-2315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE5623174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1619921392OtherNPI
TX031810701Medicaid
TX1619921392OtherNPI