Provider Demographics
NPI:1417914524
Name:STASZKIEWICZ, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:STASZKIEWICZ
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 1:1700 W PARADISE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9795
Mailing Address - Country:US
Mailing Address - Phone:262-334-3451
Mailing Address - Fax:
Practice Address - Street 1:1700 W PARADISE DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9795
Practice Address - Country:US
Practice Address - Phone:262-334-3451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38128208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics