Provider Demographics
NPI:1700945763
Name:STANLEY, DENNIS CLARK (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:CLARK
Last Name:STANLEY
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:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:HALIFAX
Mailing Address - State:VA
Mailing Address - Zip Code:24558
Mailing Address - Country:US
Mailing Address - Phone:434-575-1683
Mailing Address - Fax:434-575-1682
Practice Address - Street 1:2204 WILBORN AVENUE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592
Practice Address - Country:US
Practice Address - Phone:434-517-3187
Practice Address - Fax:434-517-3686
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010279022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
002596OtherBC
VA007242280Medicaid
002596OtherBC
300000219Medicare ID - Type Unspecified