Provider Demographics
NPI:1124588249
Name:STALLARD, MICHAEL DONALD (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DONALD
Last Name:STALLARD
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 1:5219 CAINTUCK RD
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-6516
Mailing Address - Country:US
Mailing Address - Phone:423-677-3936
Mailing Address - Fax:
Practice Address - Street 1:5219 CAINTUCK RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-6516
Practice Address - Country:US
Practice Address - Phone:423-677-3936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-24
Last Update Date:2019-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program