Provider Demographics
NPI:1396892808
Name:DONIS, STEPHAN MAXWELL (DPM)
Entity type:Individual
Prefix:
First Name:STEPHAN
Middle Name:MAXWELL
Last Name:DONIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 FARRAGUT AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:10706-3518
Mailing Address - Country:US
Mailing Address - Phone:914-674-0479
Mailing Address - Fax:
Practice Address - Street 1:270 FARRAGUT AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS ON HUDSON
Practice Address - State:NY
Practice Address - Zip Code:10706-3518
Practice Address - Country:US
Practice Address - Phone:914-674-0479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP2179213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00221353OtherRAILROAD MEDICARE
NYP22262OtherEMPIRE BCBS
432921OtherAETNA
NY01650435Medicaid
133069342OtherTAX ID
T23132Medicare UPIN
NYP22262OtherEMPIRE BCBS