Basic Information
| Provider Information | |||||||||
| NPI: | 1942497607 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STANLEY BOCZKO, MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23 E 79TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100750182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126281800 | ||||||||
| FaxNumber: | 2126281802 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 E 79TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100750182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126281800 | ||||||||
| FaxNumber: | 2126281802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2007 | ||||||||
| LastUpdateDate: | 10/25/2010 | ||||||||
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| AuthorizedOfficialLastName: | SANTIAGO | ||||||||
| AuthorizedOfficialFirstName: | MIGDALIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2126281800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 120948-1 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 00366303 | 05 | NY | MEDICAID |