Provider Demographics
NPI:1609812247
Name:STANIK, MICHAEL E (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:STANIK
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 1:811 AINSWORTH DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1687
Mailing Address - Country:US
Mailing Address - Phone:928-771-5282
Mailing Address - Fax:928-771-5283
Practice Address - Street 1:811 AINSWORTH DR
Practice Address - Street 2:SUITE 101
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1687
Practice Address - Country:US
Practice Address - Phone:928-771-5282
Practice Address - Fax:928-771-5283
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25078174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ861999Medicaid
AZAZ0755280OtherBLUE CROSS/BLUE SHIELD
AZP00143552OtherRAILROAD MEDICARE
AZP00143552OtherRAILROAD MEDICARE
AZ861999Medicaid