Provider Demographics
NPI:1619921392
Name:STASIKOWSKI, J. JOHN (MD, PA)
Entity Type:Individual
Prefix:DR
First Name:J.
Middle Name:JOHN
Last Name:STASIKOWSKI
Suffix:
Gender:M
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 8TH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4137
Mailing Address - Country:US
Mailing Address - Phone:817-926-8002
Mailing Address - Fax:
Practice Address - Street 1:1307 8TH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4137
Practice Address - Country:US
Practice Address - Phone:817-926-8002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE5623174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist