Provider Demographics
NPI:1295751782
Name:STALLONE, MARTIN JR (MD/MBA)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
Last Name:STALLONE
Suffix:JR
Gender:M
Credentials:MD/MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 DATES DR
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1342
Mailing Address - Country:US
Mailing Address - Phone:607-274-4189
Mailing Address - Fax:
Practice Address - Street 1:101 DATES DR
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1342
Practice Address - Country:US
Practice Address - Phone:607-274-4189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061023A207R00000X
RI12340208M00000X
NY253091208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine