Provider Demographics
NPI:1922095397
Name:STACKOW, JOHN CHRISTOPHER (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHRISTOPHER
Last Name:STACKOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2300
Mailing Address - Fax:208-262-2390
Practice Address - Street 1:750 N SYRINGA ST STE 190
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5275
Practice Address - Country:US
Practice Address - Phone:208-262-2328
Practice Address - Fax:208-619-5057
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-6239208600000X, 208M00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1022315Medicaid
ID1922095397Medicaid
ID000010005293OtherREGENCE BS OF ID
WA8434888Medicaid
WA43646OtherDEPT OF LABOR AND INDUSTR
CS6290Medicare Oscar/Certification
F61257Medicare UPIN
ID1373881Medicare Oscar/Certification
ID1127712Medicare PIN