Provider Demographics
NPI:1932174497
Name:STACKHOUSE, CHARLES L (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
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 1:4567 CROSSROADS PARK DR
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3589
Mailing Address - Country:US
Mailing Address - Phone:315-295-2100
Mailing Address - Fax:315-295-2125
Practice Address - Street 1:4 COULTER RD
Practice Address - Street 2:
Practice Address - City:CLIFTON SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:14432-1122
Practice Address - Country:US
Practice Address - Phone:315-462-2636
Practice Address - Fax:315-462-2638
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143099208600000X
NY1430991208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00835396Medicaid
CC8106Medicare PIN
NY00835396Medicaid