Healthcare Provider Details

I. General information

NPI: 1629539499
Provider Name (Legal Business Name): GEORGE VASILIOS STOTIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 S MOORLAND RD
NEW BERLIN WI
53151-7494
US

IV. Provider business mailing address

4855 S MOORLAND RD
NEW BERLIN WI
53151-7494
US

V. Phone/Fax

Practice location:
  • Phone: 414-425-5660
  • Fax: 414-425-9803
Mailing address:
  • Phone: 414-425-5660
  • Fax: 414-425-9803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number73768-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: