Provider Demographics
NPI:1265482616
Name:WAKULCHIK, STEPHEN DAVID JR (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DAVID
Last Name:WAKULCHIK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:135 S BRYN MAWR AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3129
Mailing Address - Country:US
Mailing Address - Phone:610-325-1390
Mailing Address - Fax:610-325-1373
Practice Address - Street 1:135 S BRYN MAWR AVE STE 200
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010
Practice Address - Country:US
Practice Address - Phone:610-325-1390
Practice Address - Fax:610-325-1373
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD034118E207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0855383Medicaid
B40860Medicare UPIN
B40860Medicare UPIN