Provider Demographics
NPI:1104386457
Name:STILLS, MADALYN JANE (DO)
Entity Type:Individual
Prefix:DR
First Name:MADALYN
Middle Name:JANE
Last Name:STILLS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 6TH ST S FL 3
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4815
Mailing Address - Country:US
Mailing Address - Phone:727-893-6116
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:700 6TH ST S FL 3
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4815
Practice Address - Country:US
Practice Address - Phone:727-893-6116
Practice Address - Fax:727-553-7430
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS17810207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113037000Medicaid