Healthcare Provider Details

I. General information

NPI: 1528562832
Provider Name (Legal Business Name): ANTHONY STEWART STACK II DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 MEASE DR STE 409
SAFETY HARBOR FL
34695-6606
US

IV. Provider business mailing address

2995 DREW ST FL 2
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 727-443-8450
  • Fax: 727-533-5911
Mailing address:
  • Phone: 727-315-7496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberUO5932
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberUO5932
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: