Provider Demographics
NPI:1376729541
Name:STANLEY J. CHESLOCK, M.D., P.A.
Entity Type:Organization
Organization Name:STANLEY J. CHESLOCK, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHESLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-529-6430
Mailing Address - Street 1:2860 CHANNING WAY
Mailing Address - Street 2:SUITE 224
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7531
Mailing Address - Country:US
Mailing Address - Phone:208-529-6430
Mailing Address - Fax:208-529-6428
Practice Address - Street 1:2860 CHANNING WAY
Practice Address - Street 2:SUITE 224
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7531
Practice Address - Country:US
Practice Address - Phone:208-529-6430
Practice Address - Fax:208-529-6428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3570207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty