Provider Demographics
NPI:1023122041
Name:STANLEY, ROBERT CHARLES (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:CHARLES
Last Name:STANLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-2018
Mailing Address - Country:US
Mailing Address - Phone:304-872-2991
Mailing Address - Fax:304-872-6268
Practice Address - Street 1:702 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-2018
Practice Address - Country:US
Practice Address - Phone:304-872-2991
Practice Address - Fax:304-872-6268
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1039207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0052008000Medicaid
WVE05903Medicare UPIN
WV0052008000Medicaid