Provider Demographics
NPI:1497706071
Name:STACK, VINCE J (MD)
Entity Type:Individual
Prefix:DR
First Name:VINCE
Middle Name:J
Last Name:STACK
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:PO BOX 2153 DEPT 40339
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35287-9387
Mailing Address - Country:US
Mailing Address - Phone:423-310-1642
Mailing Address - Fax:706-270-0487
Practice Address - Street 1:530 W 16TH ST
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2240
Practice Address - Country:US
Practice Address - Phone:719-539-6112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO46814207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO45604771Medicaid
CO301804Medicare PIN
CO45604771Medicaid