MEDICARE: DR. J. JOHN STASIKOWSKI M.D., P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	E5623	TX

General Provider Information

NPI Number	:	1619921392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. J. JOHN STASIKOWSKI M.D., P.A.

Provider Business Mailing Address
First Line	:	1307 8TH AVE
Second Line	:	SUITE 202
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4137
Country	:	US
Telephone Number	:	817-926-8002
Fax Number	:

Provider Business Practice Location Address
First Line	:	1307 8TH AVE
Second Line	:	SUITE 202
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4137
Country	:	US
Telephone Number	:	817-926-8002
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	07/08/2007

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