Basic Information
| Provider Information | |||||||||
| NPI: | 1821170424 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAVAS | ||||||||
| FirstName: | JOSEPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14441 DUPONT CT | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681442153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025978775 | ||||||||
| FaxNumber: | 4025978811 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 N 30TH ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681312128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024494416 | ||||||||
| FaxNumber: | 4024494525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 07/05/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | 17407 | NE | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 17407 | NE | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 5902317 | 05 | NC | MEDICAID |