Provider Demographics
NPI:1114017993
Name:STADNYK, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:STADNYK
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:PO BOX 2080
Mailing Address - Street 2:
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-2080
Mailing Address - Country:US
Mailing Address - Phone:804-435-3508
Mailing Address - Fax:
Practice Address - Street 1:1906 BELLEVIEW AVE SE
Practice Address - Street 2:EMERGENCY DEPT
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1838
Practice Address - Country:US
Practice Address - Phone:540-981-7000
Practice Address - Fax:540-981-9550
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234785207P00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010067481Medicaid
VA010067481Medicaid
VAP00465009Medicare PIN
VA003932C51Medicare ID - Type Unspecified
VA015822S57Medicare PIN