Provider Demographics
NPI:1487690186
Name:STAM, MARC DENTON (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:DENTON
Last Name:STAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:M
Other - Middle Name:DENTON
Other - Last Name:STAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5147 N 9TH AVE STE 318
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8710
Practice Address - Country:US
Practice Address - Phone:850-416-2965
Practice Address - Fax:850-416-1833
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME169043208G00000X
ARE-9841208G00000X
CODR.0054365208G00000X
MO2024015247208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND15573Medicaid
VA010055431Medicaid
VA010055431Medicaid
VA00X428W02Medicare PIN
NDN718403Medicare PIN
NDN715938Medicare PIN
E84682Medicare UPIN