Healthcare Provider Details

I. General information

NPI: 1154423739
Provider Name (Legal Business Name): FREDERICK J STOCKER JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3365 S 103RD ST STE 210
MILWAUKEE WI
53227-4161
US

IV. Provider business mailing address

3365 S 103RD ST STE 210
MILWAUKEE WI
53227-4161
US

V. Phone/Fax

Practice location:
  • Phone: 414-228-4800
  • Fax: 262-432-9004
Mailing address:
  • Phone: 414-228-4800
  • Fax: 262-432-9004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25789
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number25789
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number74319
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: