Provider Demographics
NPI:1275709685
Name:WILLNER, STUART M (DO)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:M
Last Name:WILLNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 NORTH DRIVE
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192
Mailing Address - Country:US
Mailing Address - Phone:734-285-3057
Mailing Address - Fax:734-285-3057
Practice Address - Street 1:222 W HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:MI
Practice Address - Zip Code:48357
Practice Address - Country:US
Practice Address - Phone:248-889-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101005829207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0558226125OtherBC BS
MI104412611Medicaid
MI104412611Medicaid
MI5822612Medicare PIN