Healthcare Provider Details

I. General information

NPI: 1538655014
Provider Name (Legal Business Name): RUSSELL STACKHOUSE MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2018
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 S 14TH ST
FERNANDINA FL
32034-3212
US

IV. Provider business mailing address

6 S 14TH ST
FERNANDINA FL
32034-3212
US

V. Phone/Fax

Practice location:
  • Phone: 904-261-5741
  • Fax: 904-261-7383
Mailing address:
  • Phone: 904-261-5741
  • Fax: 904-261-7383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME117902
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: NICHOLE RENE BARNETT
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 904-261-5741