Provider Demographics
NPI:1093824674
Name:STALICA, JENNIFER J (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:STALICA
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 1:1561 LONG POND ROAD
Mailing Address - Street 2:SUITE 408
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4135
Mailing Address - Country:US
Mailing Address - Phone:585-723-7575
Mailing Address - Fax:585-368-4890
Practice Address - Street 1:1561 LONG POND ROAD
Practice Address - Street 2:SUITE 408
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4135
Practice Address - Country:US
Practice Address - Phone:585-723-7575
Practice Address - Fax:585-368-4890
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY248623207RC0200X, 207RP1001X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02969331Medicaid
NYJ400077350/GRP70008AMedicare PIN
NY02969331Medicaid