Provider Demographics
NPI:1013139641
Name:STEFANIAK, HEATHER M (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:STEFANIAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 GREENBRIER RD STE 240
Mailing Address - Street 2:PO BOX 8900
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6519
Mailing Address - Country:US
Mailing Address - Phone:920-288-8280
Mailing Address - Fax:920-288-8285
Practice Address - Street 1:2845 GREENBRIER RD STE 240
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-8280
Practice Address - Fax:920-288-8285
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51127208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35105300Medicaid
WI026907650Medicare PIN