Healthcare Provider Details

I. General information

NPI: 1114998010
Provider Name (Legal Business Name): THOMAS PAUL STANLEY M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2606 PARK ST.
JACKSONVILLE FL
32204
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 904-388-4646
  • Fax: 904-388-9017
Mailing address:
  • Phone: 904-388-4646
  • Fax: 904-388-9017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME 0057822
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: