Provider Demographics
NPI:1336274596
Name:STUMBO, WARREN GRADY (MD)
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:GRADY
Last Name:STUMBO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:566 HIGHWAY 899
Mailing Address - Street 2:BOX 849
Mailing Address - City:HINDMAN
Mailing Address - State:KY
Mailing Address - Zip Code:41822-9998
Mailing Address - Country:US
Mailing Address - Phone:606-785-3164
Mailing Address - Fax:606-785-0107
Practice Address - Street 1:566 HIGHWAY 899
Practice Address - Street 2:
Practice Address - City:HINDMAN
Practice Address - State:KY
Practice Address - Zip Code:41822
Practice Address - Country:US
Practice Address - Phone:606-785-3164
Practice Address - Fax:606-785-0107
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2020-03-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY16312207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64162124Medicaid
KY64163124Medicaid