Provider Demographics
NPI:1487645842
Name:STEFANCIW, WAYNE KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:KENNETH
Last Name:STEFANCIW
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 1:3922 CEDAR RUN RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-9687
Mailing Address - Country:US
Mailing Address - Phone:231-935-0322
Mailing Address - Fax:231-935-0334
Practice Address - Street 1:3922 CEDAR RUN RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-9687
Practice Address - Country:US
Practice Address - Phone:231-935-0322
Practice Address - Fax:231-935-0334
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032942208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3480034Medicaid
MI3480034Medicaid
MIM61460002Medicare ID - Type Unspecified