Provider Demographics
NPI:1104819705
Name:DAJCZAK, STANISLAW P (MD)
Entity type:Individual
Prefix:
First Name:STANISLAW
Middle Name:P
Last Name:DAJCZAK
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 1:1250 RALSTON AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-5311
Mailing Address - Country:US
Mailing Address - Phone:419-783-6996
Mailing Address - Fax:419-782-8062
Practice Address - Street 1:1250 RALSTON AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-5311
Practice Address - Country:US
Practice Address - Phone:419-783-6996
Practice Address - Fax:419-782-8062
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35085114207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000362612OtherANTHEM
5598615OtherAETNA
OH04648OtherPHC
OHPO0192953OtherRRMC
OH17-98831OtherUHC
OH2542001Medicaid
OHP00192953OtherRRMC
OH4148633Medicare PIN
OH04648OtherPHC
OHP00192953OtherRRMC