Healthcare Provider Details

I. General information

NPI: 1710999487
Provider Name (Legal Business Name): JOHN R STAMM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 ANGELS PATH RD
DE PERE WI
54115-4050
US

IV. Provider business mailing address

1325 ANGELS PATH RD
DE PERE WI
54115-4050
US

V. Phone/Fax

Practice location:
  • Phone: 920-338-2855
  • Fax: 920-338-9270
Mailing address:
  • Phone: 920-338-2855
  • Fax: 920-338-9270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number30167
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: