Provider Demographics
NPI:1508887019
Name:STELLA, JOHN P (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:STELLA
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 1:12110 BUSINESS BLVD
Mailing Address - Street 2:SUITE 6, PMB 343
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7725
Mailing Address - Country:US
Mailing Address - Phone:907-726-1180
Mailing Address - Fax:
Practice Address - Street 1:1751 GARDNER WAY
Practice Address - Street 2:SUITE B
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6513
Practice Address - Country:US
Practice Address - Phone:907-357-1220
Practice Address - Fax:907-357-1222
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000161432085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8448516Medicaid
AKMD9522Medicaid
AKN2018OtherBLUE CROSS BLUE SHIELD
AKMD9522Medicaid
WA8859745Medicare ID - Type Unspecified