Healthcare Provider Details

I. General information

NPI: 1700031812
Provider Name (Legal Business Name): STEFAN L. STANESCU, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 SOUTHPARK BLVD STE C300
ST AUGUSTINE FL
32086-4162
US

IV. Provider business mailing address

PO BOX 9018
ST AUGUSTINE FL
32085-9018
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-2663
  • Fax: 904-819-0997
Mailing address:
  • Phone: 904-797-2663
  • Fax: 904-819-0997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME0076144
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberME0076144
License Number StateFL

VIII. Authorized Official

Name: STEFAN LUCIAN STANESCU
Title or Position: OWNER
Credential: MD
Phone: 904-797-2663