Provider Demographics
NPI:1114003589
Name:DICKSTEIN, STEPHEN JAY (DPM)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JAY
Last Name:DICKSTEIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 WOODSTONE DR
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4749
Mailing Address - Country:US
Mailing Address - Phone:856-346-2979
Mailing Address - Fax:
Practice Address - Street 1:53 WOODSTONE DR
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4749
Practice Address - Country:US
Practice Address - Phone:856-346-2979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00133300213E00000X
FLPO835213E00000X
PASC001587L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00261411Medicare ID - Type UnspecifiedPALMETTO GBA RAILROAD
PA104178Medicare PIN
NJ051203Medicare PIN
NJ051204Medicare PIN
T28645Medicare UPIN