Provider Demographics
NPI:1134111461
Name:STACK, ROBERT MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MICHAEL
Last Name:STACK
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:PO BOX 1560
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88004
Mailing Address - Country:US
Mailing Address - Phone:505-647-8366
Mailing Address - Fax:505-647-8381
Practice Address - Street 1:675 AVENIDA DE MESILLA
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005
Practice Address - Country:US
Practice Address - Phone:505-525-3535
Practice Address - Fax:505-527-0217
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM78268207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26210OtherPRESBYTERIAN
NM16010OtherHMO
NM2666OtherBC BS
NM0761430001OtherDMERC
NM39445593OtherCHAMPUS
NM88005C005OtherTRICARE
NM16010OtherHMO
D35981Medicare UPIN