Provider Demographics
NPI:1659844090
Name:STOLARCZYK, GERALD L (DOM)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:L
Last Name:STOLARCZYK
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 PECOS AVE
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-4158
Mailing Address - Country:US
Mailing Address - Phone:505-506-1230
Mailing Address - Fax:719-846-2941
Practice Address - Street 1:417 UNIVERSITY ST STE 1
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-2560
Practice Address - Country:US
Practice Address - Phone:505-506-1230
Practice Address - Fax:719-846-6297
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDOM1249171100000X
CO0002462171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0002462OtherCOLORADO OFFICE OF ACUPUNCTURE LICENSURE