Provider Demographics
NPI:1649432840
Name:STALLARD, GRAYDON FRANK (DO)
Entity type:Individual
Prefix:DR
First Name:GRAYDON
Middle Name:FRANK
Last Name:STALLARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2555 COURT DR SUITE 270
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054
Mailing Address - Country:US
Mailing Address - Phone:727-422-3477
Mailing Address - Fax:
Practice Address - Street 1:2555 COURT DR
Practice Address - Street 2:SUITE 450
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2134
Practice Address - Country:US
Practice Address - Phone:704-671-7652
Practice Address - Fax:704-671-7656
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-28
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017931208600000X
NC2014-01062208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery