Healthcare Provider Details

I. General information

NPI: 1679573331
Provider Name (Legal Business Name): MAREK A STAWISKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 MICHIGAN ST NE SUITE 102
GRAND RAPIDS MI
49503-3523
US

IV. Provider business mailing address

833 MICHIGAN ST NE SUITE 102
GRAND RAPIDS MI
49503-3523
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-8209
  • Fax: 616-459-0313
Mailing address:
  • Phone: 616-459-8209
  • Fax: 616-459-0313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number4301030349
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number4301030349
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: