Provider Demographics
NPI:1750313094
Name:STADNYK, MATTHEW W (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:W
Last Name:STADNYK
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:PO BOX 2153 DEPT 30755
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35287-9283
Mailing Address - Country:US
Mailing Address - Phone:314-238-5260
Mailing Address - Fax:314-821-1833
Practice Address - Street 1:12303 DEPAUL DR
Practice Address - Street 2:DEPAUL HEALTH CENTER
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-344-6350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1059552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208465724Medicaid