Provider Demographics
NPI:1306370309
Name:BANCZAK, SERINE (DO)
Entity Type:Individual
Prefix:
First Name:SERINE
Middle Name:
Last Name:BANCZAK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18751 SARICHEF LOOP
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8680
Mailing Address - Country:US
Mailing Address - Phone:908-268-9646
Mailing Address - Fax:
Practice Address - Street 1:4320 DIPLOMACY DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5925
Practice Address - Country:US
Practice Address - Phone:907-729-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.008460207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine