Provider Demographics
NPI:1023498714
Name:KAZANTSEV, STEPHANIE (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:KAZANTSEV
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:866-630-9882
Mailing Address - Fax:920-682-5810
Practice Address - Street 1:2051 PLAINFIELD RD
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-1865
Practice Address - Country:US
Practice Address - Phone:815-741-4343
Practice Address - Fax:815-741-8660
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.148350207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program