Provider Demographics
NPI:1629034764
Name:STANBACK, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:STANBACK
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 1:4508 HIGHWAY 45 N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2917
Mailing Address - Country:US
Mailing Address - Phone:662-328-9702
Mailing Address - Fax:662-328-0954
Practice Address - Street 1:4508 HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2917
Practice Address - Country:US
Practice Address - Phone:662-328-9702
Practice Address - Fax:662-328-0954
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2011-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13912207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00112134Medicaid
MSF62645Medicare UPIN
MS00112134Medicaid