Provider Demographics
NPI:1235174723
Name:ADKISSON, STANLEY W (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:W
Last Name:ADKISSON
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 1:600 RANCH RD
Mailing Address - Street 2:
Mailing Address - City:REEDSPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97467-1720
Mailing Address - Country:US
Mailing Address - Phone:541-271-2171
Mailing Address - Fax:
Practice Address - Street 1:385 RANCH RD
Practice Address - Street 2:
Practice Address - City:REEDSPORT
Practice Address - State:OR
Practice Address - Zip Code:97467-1707
Practice Address - Country:US
Practice Address - Phone:541-271-2119
Practice Address - Fax:541-271-9338
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22387207R00000X
ORMD154233207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO840428757017OtherROCKY MOUNTAIN HEALTH PLA
OR500639477Medicaid
CO01223874Medicaid
COAD376766OtherBCBS
COB84643Medicare UPIN
ORR161404Medicare PIN
CO110158293Medicare PIN
OR500639477Medicaid