Provider Demographics
NPI:1336194315
Name:BANCEREK-STENGELE, JUSTYNA (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTYNA
Middle Name:
Last Name:BANCEREK-STENGELE
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 1:1206 E 9TH ST
Mailing Address - Street 2:STE 210
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-2404
Mailing Address - Country:US
Mailing Address - Phone:815-834-8777
Mailing Address - Fax:
Practice Address - Street 1:1206 E 9TH ST
Practice Address - Street 2:STE 210
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-2404
Practice Address - Country:US
Practice Address - Phone:815-834-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036108278Medicaid
IL2489001Medicare PIN
IL036108278Medicaid
206017012Medicare PIN