Provider Demographics
NPI:1972560415
Name:STOCKALL, ERIC ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:ROBERT
Last Name:STOCKALL
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 1:2090 JOLLY RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3958
Mailing Address - Country:US
Mailing Address - Phone:517-349-3900
Mailing Address - Fax:517-349-3939
Practice Address - Street 1:2090 JOLLY RD
Practice Address - Street 2:SUITE 150
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3958
Practice Address - Country:US
Practice Address - Phone:517-349-3900
Practice Address - Fax:517-349-3939
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050188174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0330578OtherBLUE CROSS BLUE SHIELD
MI124132OtherPREFERRED CHOICES
MIC6406OtherMCARE
MI4172326Medicaid
MI0330578OtherBLUE CROSS BLUE SHIELD
C56038Medicare UPIN