Provider Demographics
NPI:1851370191
Name:STELMACK, BRUCE M (DO)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:M
Last Name:STELMACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10624 SE CHARLOTTE DR
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-2161
Mailing Address - Country:US
Mailing Address - Phone:503-498-6611
Mailing Address - Fax:888-725-5420
Practice Address - Street 1:10624 SE CHARLOTTE DR
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-2161
Practice Address - Country:US
Practice Address - Phone:503-498-6611
Practice Address - Fax:888-725-5420
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-14
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102-036910208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAE48156Medicare UPIN
VA00X562R01Medicare PIN