Healthcare Provider Details

I. General information

NPI: 1336135458
Provider Name (Legal Business Name): STEVAN J ANSELMI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WEST AVE
WELLSBORO PA
16901-1358
US

IV. Provider business mailing address

103 WEST AVE
WELLSBORO PA
16901-1358
US

V. Phone/Fax

Practice location:
  • Phone: 570-724-5297
  • Fax: 570-724-8793
Mailing address:
  • Phone: 570-724-5297
  • Fax: 570-724-8793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSC001853L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: