Provider Demographics
NPI:1568997674
Name:CAVALLARO-MORONTA, STEPHANIA PAULETTE (MD)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIA
Middle Name:PAULETTE
Last Name:CAVALLARO-MORONTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 S 2ND ST APT 602
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-2134
Mailing Address - Country:US
Mailing Address - Phone:786-469-1356
Mailing Address - Fax:
Practice Address - Street 1:2525 CHICAGO AVE STE 32-2516
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4518
Practice Address - Country:US
Practice Address - Phone:612-813-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2024-06-11
Deactivation Date:2017-11-27
Deactivation Code:
Reactivation Date:2017-12-07
Provider Licenses
StateLicense IDTaxonomies
390200000X
IAMD-470622080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program