MEDICARE: DR. DOUGLAS A STOLTZFUS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician		IL

General Provider Information

NPI Number	:	1295722742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS A STOLTZFUS MD

Provider Business Mailing Address
First Line	:	PO BOX 267836
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-7836
Country	:	US
Telephone Number	:	773-832-1081
Fax Number	:	773-832-1082

Provider Business Practice Location Address
First Line	:	1102 W PRATT BLVD
Second Line	:	APT 3E
City	:	CHICAGO
State	:	IL
Zip	:	60626-4453
Country	:	US
Telephone Number	:	773-764-4967
Fax Number	:	773-764-4967

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	07/08/2007

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