Provider Demographics
NPI:1952662868
Name:TOLKACHJOV, STANISLAV NICKOLAEVICH (MD)
Entity Type:Individual
Prefix:DR
First Name:STANISLAV
Middle Name:NICKOLAEVICH
Last Name:TOLKACHJOV
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 1:2000 STONEGATE TRL
Mailing Address - Street 2:SUITE 112
Mailing Address - City:VESTAVIA HLS
Mailing Address - State:AL
Mailing Address - Zip Code:35242-2246
Mailing Address - Country:US
Mailing Address - Phone:205-977-9876
Mailing Address - Fax:
Practice Address - Street 1:2000 STONEGATE TRL
Practice Address - Street 2:SUITE 112
Practice Address - City:VESTAVIA HLS
Practice Address - State:AL
Practice Address - Zip Code:35242-2246
Practice Address - Country:US
Practice Address - Phone:205-977-9876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN57122207N00000X
AL35179207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP01259864OtherRAILROAD MEDICARE
AL102I1071127Medicare PIN
MNH400092849Medicare PIN