Provider Demographics
NPI:1295832392
Name:WACLAWSKI, STEPHEN MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MARK
Last Name:WACLAWSKI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5312 S 27TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-3724
Mailing Address - Country:US
Mailing Address - Phone:414-281-4800
Mailing Address - Fax:414-281-4891
Practice Address - Street 1:5312 S 27TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-3724
Practice Address - Country:US
Practice Address - Phone:414-281-4800
Practice Address - Fax:414-281-4891
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1768-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI385130000Medicaid
WIT63583Medicare UPIN
WI000287540Medicare PIN