1245233063 NPI number — JOHN L STANTON M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245233063 NPI number — JOHN L STANTON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STANTON
Provider First Name:
JOHN
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245233063
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3024 BUSINESS PARK CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOODLETTSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37072-3132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-851-6033
Provider Business Mailing Address Fax Number:
615-296-9935

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
980 PROFESSIONAL PARK DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
CLARKSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37040-5251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-905-1001
Provider Business Practice Location Address Fax Number:
931-905-0410
Provider Enumeration Date:
05/24/2005

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: 174400000X , with the licence number:  MD28572 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: MD28572 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3807449 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64926090 . This is a "KENTUCKY MEDICAID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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