Provider Demographics
NPI:1902920283
Name:EKONOMIDES, CAROL STASIULEWICZ (PA)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:STASIULEWICZ
Last Name:EKONOMIDES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:CAROL
Other - Middle Name:STASIULEWICZ
Other - Last Name:EKONOMIDES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:24 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6099
Mailing Address - Country:US
Mailing Address - Phone:203-739-7411
Mailing Address - Fax:
Practice Address - Street 1:24 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6099
Practice Address - Country:US
Practice Address - Phone:203-739-7411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000169363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0021609OtherCONTROLLED SUBSTANCE REG
CTME0009298OtherFEDERAL DEA
CTS59701Medicare UPIN
CT970000248Medicare ID - Type Unspecified