Provider Demographics
NPI:1336135458
Name:ANSELMI, STEVAN J (DPM)
Entity Type:Individual
Prefix:
First Name:STEVAN
Middle Name:J
Last Name:ANSELMI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1358
Mailing Address - Country:US
Mailing Address - Phone:570-724-5297
Mailing Address - Fax:570-724-8793
Practice Address - Street 1:103 WEST AVE
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1358
Practice Address - Country:US
Practice Address - Phone:570-724-5297
Practice Address - Fax:570-724-8793
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC001853L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA442480314OtherTRAVELERS MEDICARE
PA105730Medicare PIN
T28666Medicare UPIN