Provider Demographics
NPI:1891808572
Name:STACK, THOMAS J (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:STACK
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 1:170 CHANGEBRIDGE RD
Mailing Address - Street 2:A-3
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9115
Mailing Address - Country:US
Mailing Address - Phone:973-808-3200
Mailing Address - Fax:973-808-3202
Practice Address - Street 1:170 CHANGEBRIDGE RD BLDG A3
Practice Address - Street 2:
Practice Address - City:MONTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07045-8802
Practice Address - Country:US
Practice Address - Phone:973-808-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMBO58292207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJST624751Medicare ID - Type Unspecified
NJF93378Medicare UPIN