Provider Demographics
NPI:1508836453
Name:STILLMAN, CHARLES ALLEN (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALLEN
Last Name:STILLMAN
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 1:195 GLORIA CIR
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-3559
Mailing Address - Country:US
Mailing Address - Phone:650-450-3150
Mailing Address - Fax:
Practice Address - Street 1:546 E PINE ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5525
Practice Address - Country:US
Practice Address - Phone:209-467-1000
Practice Address - Fax:209-467-7335
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A110272085R0202X
TXL47372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1508836453Medicaid
CA1508836453Medicaid