Basic Information
| Provider Information | |||||||||
| NPI: | 1316002975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STASTNY | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1920 NW 2ND ST | ||||||||
| Address2: | |||||||||
| City: | BLUE SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640141702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162283659 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 SW LONGVIEW BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640812116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132155008 | ||||||||
| FaxNumber: | 9132971202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | R2J77 | MO | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 080167543 | 01 | MO | MEDICARE RAILROAD | OTHER |