Provider Demographics
NPI:1336120005
Name:STALLMAN, PAUL T (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:T
Last Name:STALLMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2 JAMES WAY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-4973
Mailing Address - Country:US
Mailing Address - Phone:805-481-3733
Mailing Address - Fax:805-489-7376
Practice Address - Street 1:2 JAMES WAY
Practice Address - Street 2:SUITE 203
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-4973
Practice Address - Country:US
Practice Address - Phone:805-481-3733
Practice Address - Fax:805-489-7376
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81743207W00000X, 207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G817430OtherBLUE SHIELD OF CALIFORNIA
CAG81743OtherBLUE CROSS
CAG81743OtherBLUE CROSS
CA00G817430OtherBLUE SHIELD OF CALIFORNIA
P00162007Medicare PIN