Provider Demographics
NPI:1962453217
Name:STACK, SEAN (MD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:STACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 RYAN DR SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-9687
Mailing Address - Country:US
Mailing Address - Phone:503-399-1264
Mailing Address - Fax:503-371-0777
Practice Address - Street 1:2925 RYAN DR SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-9687
Practice Address - Country:US
Practice Address - Phone:503-399-1264
Practice Address - Fax:503-371-0777
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR208012085R0202X
ORMD208012085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288438Medicaid
OR288438Medicaid
ORR106408Medicare PIN