Healthcare Provider Details

I. General information

NPI: 1720127186
Provider Name (Legal Business Name): STANLEY J ZYCHOWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 04/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 RIO RANCHO DR SE PMB 283
RIO RANCHO NM
87124-1006
US

IV. Provider business mailing address

1380 RIO RANCHO DR SE PMB 283
RIO RANCHO NM
87124-1006
US

V. Phone/Fax

Practice location:
  • Phone: 575-936-9075
  • Fax:
Mailing address:
  • Phone: 575-936-9075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2005-0634
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: