Provider Demographics
NPI:1588655369
Name:WICKY VAN DOYER, STEPHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHAN
Middle Name:
Last Name:WICKY VAN DOYER
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-5774
Practice Address - Fax:774-441-8443
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2238402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2103923Medicaid
MA110040985AMedicaid
MAJ26427OtherBCBS OF MA
MA213058OtherTUFTS HEALTH PLAN
H81360Medicare UPIN