Provider Demographics
NPI:1982678553
Name:VANBLARCOM, STEPHEN THADDEUS (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:THADDEUS
Last Name:VANBLARCOM
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1126 S 70TH STREET
Mailing Address - Street 2:SUITE N500
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214
Mailing Address - Country:US
Mailing Address - Phone:414-455-4780
Mailing Address - Fax:414-475-2936
Practice Address - Street 1:10400 W NORTH AVENUE
Practice Address - Street 2:SUITE 300
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214
Practice Address - Country:US
Practice Address - Phone:414-771-7470
Practice Address - Fax:414-771-7433
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI28611-0202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31516400Medicaid
WI31516400Medicaid