Provider Demographics
NPI:1912155250
Name:STANELLE, ERIC JON (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JON
Last Name:STANELLE
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 1:2000 E MILESTONE DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-6701
Mailing Address - Country:US
Mailing Address - Phone:920-731-8131
Mailing Address - Fax:920-832-0444
Practice Address - Street 1:2000 E MILESTONE DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-6701
Practice Address - Country:US
Practice Address - Phone:920-731-8131
Practice Address - Fax:920-832-0444
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA251367208600000X
WI65876-20208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400154845Medicare PIN