1306966379 NPI number — MARIA MARTHA STECK O.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306966379 NPI number — MARIA MARTHA STECK O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STECK
Provider First Name:
MARIA
Provider Middle Name:
MARTHA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306966379
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12520 MAC ALISTER WAY UNIT 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BERLIN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53151-8333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-628-4264
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11530 W BURLEIGH ST
Provider Second Line Business Practice Location Address:
SPACE 110
Provider Business Practice Location Address City Name:
WAUWATOSA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-453-2275
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152WC0802X , with the licence number:  2342 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 2342 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2342 . This is a "STATE LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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