Provider Demographics
NPI:1710972047
Name:STALLKAMP, ERIC TODD (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:TODD
Last Name:STALLKAMP
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:PO BOX 636930
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:513-981-5123
Mailing Address - Fax:513-981-5015
Practice Address - Street 1:582 N CABLE RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-2133
Practice Address - Country:US
Practice Address - Phone:419-996-2500
Practice Address - Fax:419-996-2509
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350731165207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH080142578OtherTRAVELERS/RAILROAD MEDICA
1134112469OtherGROUP NPI# PRIMARY OFFICE
OH2062075Medicaid
OH000000136496OtherANTHEM BC/BS PROVIDER #
1669550182OtherGROUP NPI# SATELLITE OFFI
OH2062075Medicaid
OHST0854705Medicare PIN
ST0854702Medicare ID - Type Unspecified