Provider Demographics
NPI:1891915138
Name:STALZER, RICHARD CLARENCE
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CLARENCE
Last Name:STALZER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 WEST CANTERBURY LN
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 WEST CHICAGO AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-4331
Practice Address - Country:US
Practice Address - Phone:312-926-3964
Practice Address - Fax:312-926-3028
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D89086Medicare UPIN