Provider Demographics
NPI:1326047069
Name:STOCKWELL, FREDERICK DAVIS (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:DAVIS
Last Name:STOCKWELL
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 1:50 N. PROGRESS DR.
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385
Mailing Address - Country:US
Mailing Address - Phone:937-374-4040
Mailing Address - Fax:937-374-4020
Practice Address - Street 1:50 N. PROGRESS DR.
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385
Practice Address - Country:US
Practice Address - Phone:937-374-4040
Practice Address - Fax:937-374-4020
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043256207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000012506OtherANTHEM
OH0402317Medicaid
OHP00432937OtherRAILROAD MEDICARE
OH0402317Medicaid
A79043Medicare UPIN
OH0469051Medicare PIN