Provider Demographics
NPI:1205821527
Name:PODRYGULA, STEPHAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHAN
Middle Name:
Last Name:PODRYGULA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 22ND AVE NW
Mailing Address - Street 2:NORTHLAND PROFESSIONAL BUILDING
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-0986
Mailing Address - Country:US
Mailing Address - Phone:701-852-9113
Mailing Address - Fax:701-838-0779
Practice Address - Street 1:600 22ND AVE NW
Practice Address - Street 2:NORTHLAND PROFESSIONAL BUILDING
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-0986
Practice Address - Country:US
Practice Address - Phone:701-852-9113
Practice Address - Fax:701-838-0779
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND136103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDPOD5241OtherBLUE CROSS BLUE SHIELD
ND16946Medicaid
ND16946Medicaid