Healthcare Provider Details

I. General information

NPI: 1326182460
Provider Name (Legal Business Name): DR. STANLEY RACZEK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG H-100 SANTA MARGARITA ROAD NAVAL HOSPITAL
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

5089 MANOR RIDGE LN
SAN DIEGO CA
92130-2895
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-8882
  • Fax: 760-725-1267
Mailing address:
  • Phone: 760-725-1555
  • Fax: 760-725-1267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number143076
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: