Provider Demographics
NPI:1467417121
Name:STOLZ, GERALD A JR (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:A
Last Name:STOLZ
Suffix:JR
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:PO BOX 925
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811
Mailing Address - Country:US
Mailing Address - Phone:479-968-6781
Mailing Address - Fax:479-968-3074
Practice Address - Street 1:1430 WEST C STREET
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801
Practice Address - Country:US
Practice Address - Phone:479-968-6781
Practice Address - Fax:479-968-3074
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4316207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100076190AMedicaid
AR770120601OtherBREASTCARE
AR103867001Medicaid
AR103867001Medicaid
AR55137Medicare ID - Type Unspecified