Provider Demographics
NPI:1295707586
Name:STAMBAUGH, MERRIS A (MD)
Entity type:Individual
Prefix:DR
First Name:MERRIS
Middle Name:A
Last Name:STAMBAUGH
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 1:1107A BROOKDALE ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-4501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1107 BROOKDALE ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-4501
Practice Address - Country:US
Practice Address - Phone:276-670-3300
Practice Address - Fax:276-634-0379
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-058735207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005638674Medicaid
VA080006975Medicare PIN
G89504Medicare UPIN
VA005638674Medicaid