Provider Demographics
NPI:1538655014
Name:RUSSELL STACKHOUSE MD PA
Entity Type:Organization
Organization Name:RUSSELL STACKHOUSE MD PA
Other - Org Name:COASTAL VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:BARNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-261-5741
Mailing Address - Street 1:6 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3212
Mailing Address - Country:US
Mailing Address - Phone:904-261-5741
Mailing Address - Fax:904-261-7383
Practice Address - Street 1:6 S 14TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA
Practice Address - State:FL
Practice Address - Zip Code:32034-3212
Practice Address - Country:US
Practice Address - Phone:904-261-5741
Practice Address - Fax:904-261-7383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-08
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME117902207W00000X
207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
070583OtherDATE OF BIRTH