Provider Demographics
NPI:1265415558
Name:STADWISER, J BRUCE (MD)
Entity type:Individual
Prefix:
First Name:J
Middle Name:BRUCE
Last Name:STADWISER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2327 E CAROL AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-4614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 W THOMAS RD
Practice Address - Street 2:SUITE # 250
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4224
Practice Address - Country:US
Practice Address - Phone:602-263-9345
Practice Address - Fax:602-263-0778
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6395207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ200858Medicaid
AZ18WCKCW06Medicare ID - Type Unspecified
AZ18WCGTH07Medicare PIN
AZD00366Medicare UPIN