Provider Demographics
NPI:1205822202
Name:STALL, ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:STALL
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 1:4242 RIDGE LEA RD STE 26
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-5120
Mailing Address - Country:US
Mailing Address - Phone:716-833-3237
Mailing Address - Fax:888-976-5853
Practice Address - Street 1:4242 RIDGE LEA RD STE 26
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226
Practice Address - Country:US
Practice Address - Phone:716-833-3237
Practice Address - Fax:888-976-5853
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-25
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163872-1207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01207083-2Medicaid
NY026621Medicare ID - Type Unspecified
NY01207083-2Medicaid