Healthcare Provider Details

I. General information

NPI: 1174516082
Provider Name (Legal Business Name): STEPHEN E. PLISKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 03/29/2012
Certification Date:
Deactivation Date: 03/27/2006
Reactivation Date: 04/21/2006

III. Provider practice location address

7701 NE HIGHWAY 99
VANCOUVER WA
98665-8834
US

IV. Provider business mailing address

4421 NE ST JOHNS RD
VANCOUVER WA
98661-2573
US

V. Phone/Fax

Practice location:
  • Phone: 360-574-2900
  • Fax:
Mailing address:
  • Phone: 360-695-9922
  • Fax: 360-695-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number12789
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: