Provider Demographics
NPI:1518918416
Name:STOCKWELL, DOUGLAS J (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:STOCKWELL
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 1:3030 N CENTRAL AVE STE 1001
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2716
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:913-636-4358
Practice Address - Street 1:500 W THOMAS RD STE 230
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013
Practice Address - Country:US
Practice Address - Phone:602-406-9999
Practice Address - Fax:602-406-8099
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG56532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ114122Medicaid
TX076126OtherVALUE OPTIONS
TX137426604Medicaid
TX260041159OtherRAILROAD MEDICARE
TX85500XOtherBLUE CROSS BLUE SHIELD
TX137426604Medicaid