Provider Demographics
NPI:1053626945
Name:J DEAN STOCKSTILL MD, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:J DEAN STOCKSTILL MD, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:STOCKSTILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-323-7576
Mailing Address - Street 1:3510 MAGNOLIA CV
Mailing Address - Street 2:SUITE 190
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-2372
Mailing Address - Country:US
Mailing Address - Phone:318-323-7576
Mailing Address - Fax:318-322-7131
Practice Address - Street 1:3510 MAGNOLIA CV
Practice Address - Street 2:SUITE 190
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-2372
Practice Address - Country:US
Practice Address - Phone:318-323-7576
Practice Address - Fax:318-322-7131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL06937R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty