Provider Demographics
NPI:1780788190
Name:STEPANCZUK, PAUL PHILLIP (DPM)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:PHILLIP
Last Name:STEPANCZUK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3962
Mailing Address - Country:US
Mailing Address - Phone:219-836-9488
Mailing Address - Fax:219-836-9497
Practice Address - Street 1:1650 45TH AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3962
Practice Address - Country:US
Practice Address - Phone:219-836-9488
Practice Address - Fax:219-836-9497
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000758213ES0131X
IL213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL90000152OtherBLUE CROSS BL SHIELD
IN6002117465OtherBLUE CROSS BL SHIELD
IN6002117465OtherBLUE CROSS BL SHIELD
IL90000152OtherBLUE CROSS BL SHIELD
IL647340Medicare ID - Type Unspecified