Provider Demographics
NPI:1063803963
Name:GUTIONTOV, STANLEY (MD)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:GUTIONTOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11516 N PORT WASHINGTON RD STE 107
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3478
Mailing Address - Country:US
Mailing Address - Phone:262-241-5040
Mailing Address - Fax:262-241-5040
Practice Address - Street 1:1222 N 23RD ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3171
Practice Address - Country:US
Practice Address - Phone:920-457-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.0698172085R0001X
WI754652085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology