Healthcare Provider Details

I. General information

NPI: 1588664932
Provider Name (Legal Business Name): PAUL T. STOCKMANN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11123 PARKVIEW PLAZA DR STE 200
FORT WAYNE IN
46845-1707
US

IV. Provider business mailing address

CHILDRENS HOSPITAL OF MICHIGAN 3901 BEAUBIEN BLVD
DETROIT MI
48201
US

V. Phone/Fax

Practice location:
  • Phone: 260-425-6100
  • Fax: 260-425-6105
Mailing address:
  • Phone: 313-831-3220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number057466
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number01078636A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: