Provider Demographics
NPI:1780895581
Name:STENFORS-DACRE, CELIA (MD)
Entity type:Individual
Prefix:DR
First Name:CELIA
Middle Name:
Last Name:STENFORS-DACRE
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 1:400 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:MI
Mailing Address - Zip Code:49098-9225
Mailing Address - Country:US
Mailing Address - Phone:269-463-3600
Mailing Address - Fax:
Practice Address - Street 1:400 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:MI
Practice Address - Zip Code:49098-9225
Practice Address - Country:US
Practice Address - Phone:269-463-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9720208100000X
WY6167A208100000X
IL036-095198208100000X
MI4301500417208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY114527400Medicaid
WYG55442Medicare UPIN
WY308115Medicare ID - Type UnspecifiedGROUP