Provider Demographics
NPI:1649320532
Name:STAHLY, RANDALL L (DO)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:L
Last Name:STAHLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:3004 GORDONVILLE RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5008
Practice Address - Country:US
Practice Address - Phone:573-332-1972
Practice Address - Fax:573-334-4667
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR64552084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240926832Medicaid