Provider Demographics
NPI:1295722742
Name:STOLTZFUS, DOUGLAS A (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:A
Last Name:STOLTZFUS
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:PO BOX 267836
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-7836
Mailing Address - Country:US
Mailing Address - Phone:773-832-1081
Mailing Address - Fax:773-832-1082
Practice Address - Street 1:1102 W PRATT BLVD
Practice Address - Street 2:APT 3E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-4453
Practice Address - Country:US
Practice Address - Phone:773-764-4967
Practice Address - Fax:773-764-4967
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F48934Medicare UPIN
201825Medicare ID - Type Unspecified