Provider Demographics
NPI:1720017346
Name:STALLWORTH, JAMES R (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:R
Last Name:STALLWORTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-293-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:14 MEDICAL PARK RD
Practice Address - Street 2:SUITE 400
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6877
Practice Address - Country:US
Practice Address - Phone:803-255-3422
Practice Address - Fax:803-255-3451
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9582208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC95827Medicaid
F504282389Medicare ID - Type Unspecified
F50428Medicare UPIN