Individual
DR. DMITRIY STALIVONENKO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
10400 75TH ST, KENOSHA, WI 53142-7884
(414) 358-5443
Mailing address
PO BOX 735044, CHICAGO, IL 60673-5044
(414) 358-5443
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
40879-020
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
34055600
—
WI
Enumeration date
01/12/2006
Last updated
11/06/2023
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