Provider Demographics
NPI:1740223825
Name:STODDARD, CHRISTOPHER DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:DAVID
Last Name:STODDARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HARRINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2920
Mailing Address - Country:US
Mailing Address - Phone:586-493-8098
Mailing Address - Fax:
Practice Address - Street 1:1000 HARRINGTON ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2920
Practice Address - Country:US
Practice Address - Phone:586-493-8098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010148992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI310B510660OtherBCBSM
MICI8050OtherMEDICARE RR GROUP
MIP00316327OtherRAILROAD MEDICARE
MI310E011330OtherBCBS GROUP
MI4878328Medicaid
MII52993Medicare UPIN
MIP00316327OtherRAILROAD MEDICARE
MI0M74500Medicare PIN