Provider Demographics
NPI:1710915855
Name:STANCZAK, LAURIE C (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:C
Last Name:STANCZAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51086 FAIRCHILD RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48051-1998
Mailing Address - Country:US
Mailing Address - Phone:586-421-3160
Mailing Address - Fax:586-421-3161
Practice Address - Street 1:51086 FAIRCHILD RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48051-1998
Practice Address - Country:US
Practice Address - Phone:586-421-3160
Practice Address - Fax:586-421-3161
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI068457207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4331576Medicaid
MI0E06281019Medicare ID - Type Unspecified
MI4331576Medicaid