Provider Demographics
NPI:1023094851
Name:STALLWORTH, ROBERT J (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:STALLWORTH
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 1:210 25TH AVE N
Mailing Address - Street 2:SUITE 602
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1606
Mailing Address - Country:US
Mailing Address - Phone:615-312-0600
Mailing Address - Fax:615-320-3259
Practice Address - Street 1:210 25TH AVE N STE 602
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203
Practice Address - Country:US
Practice Address - Phone:615-312-0600
Practice Address - Fax:615-320-3259
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH75112085R0202X
LAMD0193822085R0202X
TN253932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64037021Medicaid
TN1519675OtherTSC
TN3084906OtherTNONC
TN3084906Medicaid
TN1509515OtherIANP
3791068Medicare ID - Type Unspecified
E88909Medicare UPIN
TN3791307Medicare ID - Type UnspecifiedSMRI
3791307Medicare ID - Type Unspecified
TN3721492Medicaid
TN3084908Medicare ID - Type Unspecified