Provider Demographics
NPI:1699720250
Name:STADALSKY, JOHN SCOTT (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:SCOTT
Last Name:STADALSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SCOTT
Other - Middle Name:
Other - Last Name:STADALSKY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1871 SAVAGE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-4726
Mailing Address - Country:US
Mailing Address - Phone:843-531-9961
Mailing Address - Fax:866-533-4473
Practice Address - Street 1:105 SPRINGHALL DR
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-5370
Practice Address - Country:US
Practice Address - Phone:843-766-6308
Practice Address - Fax:866-533-4473
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24015208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT83086Medicaid
SC571020809007OtherBCBS SC
SC571020809042OtherTRICARE
SCT83086Medicaid
6795Medicare ID - Type Unspecified