Provider Demographics
NPI:1720127186
Name:ZYCHOWSKI, STANLEY J (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:J
Last Name:ZYCHOWSKI
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 1:1380 RIO RANCHO DR SE
Mailing Address - Street 2:PMB 283
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1006
Mailing Address - Country:US
Mailing Address - Phone:575-936-9075
Mailing Address - Fax:
Practice Address - Street 1:1380 RIO RANCHO DR SE
Practice Address - Street 2:PMB 283
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1006
Practice Address - Country:US
Practice Address - Phone:575-936-9075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0634208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9137114Medicaid
CO9137114Medicaid