Provider Demographics
NPI:1922663491
Name:STOCKETT, ROBERT LEWIS III
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEWIS
Last Name:STOCKETT
Suffix:III
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 1:4515 POPLAR AVE STE 108-B
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-7503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4515 POPLAR AVE STE 108-B
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-7503
Practice Address - Country:US
Practice Address - Phone:901-767-3045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN830174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist