Provider Demographics
NPI:1336468636
Name:STAVAS, MARK JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:STAVAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4101 TIGER LILY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-5587
Mailing Address - Country:US
Mailing Address - Phone:402-420-7000
Mailing Address - Fax:402-420-6969
Practice Address - Street 1:4101 TIGER LILY RD STE 100
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-5587
Practice Address - Country:US
Practice Address - Phone:402-420-7000
Practice Address - Fax:402-420-6969
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD531472085R0001X
NE303952085R0001X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ017678Medicaid