Provider Demographics
NPI:1699773291
Name:STAUBER, STUART LANCE (MD)
Entity type:Individual
Prefix:DR
First Name:STUART
Middle Name:LANCE
Last Name:STAUBER
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 1:3415 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-1450
Mailing Address - Country:US
Mailing Address - Phone:718-278-2727
Mailing Address - Fax:
Practice Address - Street 1:3415 31ST AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-1450
Practice Address - Country:US
Practice Address - Phone:718-278-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136356207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00759673Medicaid
NY00759673Medicaid
NY55974Medicare ID - Type Unspecified