Provider Demographics
NPI:1881496420
Name:STACKS, JERALD (DO)
Entity type:Individual
Prefix:
First Name:JERALD
Middle Name:
Last Name:STACKS
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 N BAYSHORE DR APT 3131
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33132-2706
Mailing Address - Country:US
Mailing Address - Phone:305-299-8922
Mailing Address - Fax:
Practice Address - Street 1:300 SINGLETON RIDGE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9142
Practice Address - Country:US
Practice Address - Phone:843-234-7405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty