Provider Demographics
NPI:1679573331
Name:STAWISKI, MAREK A (MD)
Entity type:Individual
Prefix:MR
First Name:MAREK
Middle Name:A
Last Name:STAWISKI
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 1:833 MICHIGAN ST NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3523
Mailing Address - Country:US
Mailing Address - Phone:616-459-8209
Mailing Address - Fax:616-459-0313
Practice Address - Street 1:833 MICHIGAN ST NE
Practice Address - Street 2:SUITE 102
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3523
Practice Address - Country:US
Practice Address - Phone:616-459-8209
Practice Address - Fax:616-459-0313
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301030349207ND0900X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0724106641OtherBCBSM
MI4687587Medicaid
MIP00236428OtherRRB MEDICARE
MIP09760002Medicare Oscar/Certification
MI0724106641OtherBCBSM
MI4687587Medicaid