Provider Demographics
NPI:1629539499
Name:STOTIS, GEORGE VASILIOS (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:VASILIOS
Last Name:STOTIS
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 1:4855 S MOORLAND RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-7494
Mailing Address - Country:US
Mailing Address - Phone:414-425-5660
Mailing Address - Fax:414-425-9803
Practice Address - Street 1:4855 S MOORLAND RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7494
Practice Address - Country:US
Practice Address - Phone:414-425-5660
Practice Address - Fax:414-425-9803
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73768-20208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1629539499Medicaid