Provider Demographics
NPI:1497771471
Name:STANIEC, MICHAEL DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DOUGLAS
Last Name:STANIEC
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 1:42429 N CROSS TIMBERS CT
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-1098
Mailing Address - Country:US
Mailing Address - Phone:623-551-1097
Mailing Address - Fax:602-548-2470
Practice Address - Street 1:5601 W EUGIE AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1255
Practice Address - Country:US
Practice Address - Phone:602-548-1600
Practice Address - Fax:602-548-2470
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD10600Medicare ID - Type Unspecified
AZD37691Medicare UPIN