Provider Demographics
NPI:1447252234
Name:STAUB, SVETLANA ALEXANDRA (MD)
Entity type:Individual
Prefix:
First Name:SVETLANA
Middle Name:ALEXANDRA
Last Name:STAUB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 DELANEY RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6013
Mailing Address - Country:US
Mailing Address - Phone:910-763-3349
Mailing Address - Fax:910-251-9428
Practice Address - Street 1:2304 DELANEY RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6013
Practice Address - Country:US
Practice Address - Phone:910-763-3349
Practice Address - Fax:910-251-9428
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20060096208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904552Medicaid