Provider Demographics
NPI:1326041187
Name:STANLEY, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:STANLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36561 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-2012
Mailing Address - Country:US
Mailing Address - Phone:586-791-0620
Mailing Address - Fax:586-791-5565
Practice Address - Street 1:36561 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48035-2012
Practice Address - Country:US
Practice Address - Phone:586-791-0620
Practice Address - Fax:586-791-5565
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010543762085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301054376OtherSTATE LICENSE
F86678Medicare UPIN