Provider Demographics
NPI:1922578343
Name:STOCKDALE, GREGORY DAVID
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:DAVID
Last Name:STOCKDALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:553 HATHAWAY TRL
Mailing Address - Street 2:
Mailing Address - City:TIPP CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45371-1154
Mailing Address - Country:US
Mailing Address - Phone:937-308-3807
Mailing Address - Fax:
Practice Address - Street 1:600 WAYNE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410-1122
Practice Address - Country:US
Practice Address - Phone:937-496-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health