Provider Demographics
NPI:1568446300
Name:KARBON, STACI M (MD)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:M
Last Name:KARBON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 COMMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-6089
Mailing Address - Country:US
Mailing Address - Phone:920-430-4585
Mailing Address - Fax:
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-6089
Practice Address - Country:US
Practice Address - Phone:920-430-4585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41332208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV41332OtherLICENSE
WI000009Medicare Oscar/Certification
WI000034Medicare Oscar/Certification
WV41332OtherLICENSE
WIG97657Medicare UPIN