Provider Demographics
NPI:1417999301
Name:STANLEY, MARKUS B (DO)
Entity Type:Individual
Prefix:DR
First Name:MARKUS
Middle Name:B
Last Name:STANLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 KING ARTHURS RDG
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-9767
Mailing Address - Country:US
Mailing Address - Phone:601-636-0528
Mailing Address - Fax:601-883-0197
Practice Address - Street 1:110 KING ARTHURS RDG
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-9767
Practice Address - Country:US
Practice Address - Phone:601-636-0528
Practice Address - Fax:601-883-0197
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13941207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00112135Medicaid
MS080004047Medicare ID - Type Unspecified
MS00112135Medicaid