Provider Demographics
NPI:1750517710
Name:STACKHOUSE, JAMES RUSSELL KELLER (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RUSSELL KELLER
Last Name:STACKHOUSE
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 1:6 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3212
Mailing Address - Country:US
Mailing Address - Phone:904-261-5741
Mailing Address - Fax:904-261-7383
Practice Address - Street 1:6 S 14TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA
Practice Address - State:FL
Practice Address - Zip Code:32034
Practice Address - Country:US
Practice Address - Phone:904-261-5741
Practice Address - Fax:904-261-7383
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA770778207W00000X
FLME117902207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100661200Medicaid