Provider Demographics
NPI:1093892192
Name:MIELNICKI, STANLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:
Last Name:MIELNICKI
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 1:6 WOODSTOCK DR
Mailing Address - Street 2:
Mailing Address - City:SAYLORSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18353
Mailing Address - Country:US
Mailing Address - Phone:570-588-6197
Mailing Address - Fax:
Practice Address - Street 1:5221 MILFORD RD
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18302-9149
Practice Address - Country:US
Practice Address - Phone:570-588-6197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038202E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016678300001Medicaid
PA505354KLFMedicare PIN
PA0016678300001Medicaid