Provider Demographics
NPI:1821044009
Name:STOCK, EDWIN LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:LEE
Last Name:STOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:E.
Other - Middle Name:LEE
Other - Last Name:STOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:630 SHADY RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-9532
Mailing Address - Country:US
Mailing Address - Phone:866-926-7632
Mailing Address - Fax:414-921-9641
Practice Address - Street 1:2500 N MAYFAIR RD
Practice Address - Street 2:SUITE 340
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-1409
Practice Address - Country:US
Practice Address - Phone:866-926-7632
Practice Address - Fax:414-921-4919
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41620207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32587400Medicaid
C38730Medicare UPIN