Healthcare Provider Details

I. General information

NPI: 1699930990
Provider Name (Legal Business Name): KEVIN MICHAEL STOCKMASTER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10315 DAWSONS CREEK BLVD STE AB
FORT WAYNE IN
46825-1912
US

IV. Provider business mailing address

PO BOX 843603
DALLAS TX
75284-0001
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-7875
  • Fax: 260-432-9812
Mailing address:
  • Phone: 972-233-1999
  • Fax: 972-233-3666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number02003226A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: