Provider Demographics
NPI:1558346601
Name:STALL, HOMER PHILLIPS (MD)
Entity Type:Individual
Prefix:
First Name:HOMER
Middle Name:PHILLIPS
Last Name:STALL
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 1:200 E SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3142
Mailing Address - Country:US
Mailing Address - Phone:321-725-4500
Mailing Address - Fax:321-724-4324
Practice Address - Street 1:200 E SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3142
Practice Address - Country:US
Practice Address - Phone:321-725-4500
Practice Address - Fax:321-724-4324
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME25910207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
05341ZMedicare ID - Type Unspecified
D51245Medicare UPIN