Provider Demographics
NPI:1457312597
Name:STALLWORTH, WILLIAM ALVIN (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ALVIN
Last Name:STALLWORTH
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 1:1272 W MAIN ST STE 401
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2056
Mailing Address - Country:US
Mailing Address - Phone:220-564-1750
Mailing Address - Fax:220-564-1751
Practice Address - Street 1:1272 W MAIN ST STE 401
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2056
Practice Address - Country:US
Practice Address - Phone:220-564-1750
Practice Address - Fax:220-564-1751
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-059328208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0768094Medicaid
OH0656526Medicare PIN
D14469Medicare UPIN
OHST0656524Medicare PIN