Provider Demographics
NPI:1457462418
Name:FANDERCLAI, ROBYN MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:ROBYN
Middle Name:MICHELLE
Last Name:FANDERCLAI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ROBYN
Other - Middle Name:MICHELLE
Other - Last Name:STENGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:9209 PHOENIX VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-4280
Practice Address - Country:US
Practice Address - Phone:636-561-4613
Practice Address - Fax:636-561-4610
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003005421207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000014322Medicare ID - Type Unspecified
MOH88089Medicare UPIN