Provider Demographics
NPI:1750388971
Name:STANCZAK, AVA CHERYL (DO)
Entity type:Individual
Prefix:
First Name:AVA
Middle Name:CHERYL
Last Name:STANCZAK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 FARRIS MINES RD
Mailing Address - Street 2:
Mailing Address - City:ALLISONIA
Mailing Address - State:VA
Mailing Address - Zip Code:24347-4072
Mailing Address - Country:US
Mailing Address - Phone:540-230-4668
Mailing Address - Fax:
Practice Address - Street 1:645 E STATE HIGHWAY 121 STE 600
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-7942
Practice Address - Country:US
Practice Address - Phone:972-745-7500
Practice Address - Fax:972-745-4336
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01022011441208000000X
TXG4785208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0102201441Medicaid
VAC12781Medicare UPIN