Provider Demographics
NPI:1669459905
Name:STIPANUK, GERALD S (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:S
Last Name:STIPANUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 WINDOVER RD # 6009
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-6007
Mailing Address - Country:US
Mailing Address - Phone:870-204-0534
Mailing Address - Fax:731-235-0559
Practice Address - Street 1:1007 WINDOVER RD # 6009
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6007
Practice Address - Country:US
Practice Address - Phone:870-520-6473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2024-07-12
Deactivation Date:2017-11-01
Deactivation Code:
Reactivation Date:2017-11-21
Provider Licenses
StateLicense IDTaxonomies
TN29939207R00000X
ARE-7145207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4217156OtherBCBS TN
TN1511734Medicaid
KY0000006613645OtherBCBS KY
KY0000006613645OtherBCBS KY
B46329Medicare UPIN