1215971338 NPI number — SANDRA CAROLE STUBBLEFIELD MD

Table of content: SANDRA CAROLE STUBBLEFIELD MD (NPI 1215971338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215971338 NPI number — SANDRA CAROLE STUBBLEFIELD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STUBBLEFIELD
Provider First Name:
SANDRA
Provider Middle Name:
CAROLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STUBBLEFIELD
Provider Other First Name:
SANDRA
Provider Other Middle Name:
CAROLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1215971338
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1960
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72403-1960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-936-8000
Provider Business Mailing Address Fax Number:
870-932-1293

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8170 US HIGHWAY 49N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLAND
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-936-8000
Provider Business Practice Location Address Fax Number:
870-932-1293
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  C-7544 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 119256001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080045762 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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