Provider Demographics
NPI:1598859837
Name:STAZZONE, MADELYN M (MD)
Entity Type:Individual
Prefix:DR
First Name:MADELYN
Middle Name:M
Last Name:STAZZONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8131
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-7092
Mailing Address - Fax:314-747-4189
Practice Address - Street 1:510 S KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1016
Practice Address - Country:US
Practice Address - Phone:314-362-7092
Practice Address - Fax:314-747-4189
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030064132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431010377Medicaid
MO431010377Medicare PIN