Provider Demographics
NPI:1285670539
Name:PAUKOVITZ, STACEY A (DPM)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:PAUKOVITZ
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 ATLANTIC AVE
Mailing Address - Street 2:BLDG C, STE 3
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-0873
Mailing Address - Country:US
Mailing Address - Phone:732-528-2218
Mailing Address - Fax:732-528-2234
Practice Address - Street 1:1903 ATLANTIC AVE
Practice Address - Street 2:BLDG C, STE 3
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-0873
Practice Address - Country:US
Practice Address - Phone:732-528-2218
Practice Address - Fax:732-528-2234
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00269900213ES0103X
NJMD00269900213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU81100Medicare UPIN