Provider Demographics
NPI:1609873918
Name:BRYSACZ, STANLEY P JR (DO)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:P
Last Name:BRYSACZ
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6565 E GREENWAY PKWY
Mailing Address - Street 2:STE 100
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-2056
Mailing Address - Country:US
Mailing Address - Phone:480-348-3200
Mailing Address - Fax:480-348-3210
Practice Address - Street 1:6565 E GREENWAY PKWY
Practice Address - Street 2:STE 100
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-2056
Practice Address - Country:US
Practice Address - Phone:480-348-3200
Practice Address - Fax:480-348-3210
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ1207207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ260985Medicaid
E46840Medicare UPIN
AZ260985Medicaid