Provider Demographics
NPI:1205845799
Name:WISNIEWSKI, STANLEY J (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:J
Last Name:WISNIEWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3691 CHANEYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:OWINGS
Mailing Address - State:MD
Mailing Address - Zip Code:20736-9134
Mailing Address - Country:US
Mailing Address - Phone:410-257-0215
Mailing Address - Fax:
Practice Address - Street 1:8191 JENNIFER LN
Practice Address - Street 2:150
Practice Address - City:OWINGS
Practice Address - State:MD
Practice Address - Zip Code:20736-3194
Practice Address - Country:US
Practice Address - Phone:443-964-5159
Practice Address - Fax:443-964-5149
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0062090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDI22807Medicare UPIN