Provider Demographics
NPI:1083662688
Name:STALLWORTH, DAVID KERN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:KERN
Last Name:STALLWORTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:2016 S ALABAMA AVE
Practice Address - Street 2:
Practice Address - City:MONROEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36460-3044
Practice Address - Country:US
Practice Address - Phone:205-180-3606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14114208600000X
AL00014114207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
051513418OtherMCH SURG MCARE PROV. NO.
AL051513418OtherMCH SURG BCBS PROV. NO.
020054555OtherMCH SURG RAILROAD PROVIDE
AL051556564Medicaid
AL009910385OtherMCH SURG MEDICAID PROV
AL051513418OtherMCH SURG BCBS PROV. NO.
051513418OtherMCH SURG MCARE PROV. NO.