Provider Demographics
NPI:1689075483
Name:STUBBS, ANTHONY LAMAR
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:LAMAR
Last Name:STUBBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 PAGE ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-4931
Mailing Address - Country:US
Mailing Address - Phone:616-389-4554
Mailing Address - Fax:
Practice Address - Street 1:36 PAGE ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-4931
Practice Address - Country:US
Practice Address - Phone:616-389-4554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-11
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2615343900000X, 261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)