Provider Demographics
NPI:1114998010
Name:STANLEY, THOMAS PAUL (M D)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:PAUL
Last Name:STANLEY
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:904-388-4646
Mailing Address - Fax:904-388-9017
Practice Address - Street 1:2606 PARK ST.
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204
Practice Address - Country:US
Practice Address - Phone:904-388-4646
Practice Address - Fax:904-388-9017
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0057822208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0643840-00Medicaid
FL0643840-00Medicaid
B18593Medicare UPIN