Healthcare Provider Details

I. General information

NPI: 1376714816
Provider Name (Legal Business Name): WARREN STACKS MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 04/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 WESTGATE CENTER DR STE 140
WINSTON SALEM NC
27103-3104
US

IV. Provider business mailing address

PO BOX 30249
WINSTON SALEM NC
27130-0249
US

V. Phone/Fax

Practice location:
  • Phone: 336-659-9440
  • Fax: 336-659-9845
Mailing address:
  • Phone: 336-659-9440
  • Fax: 336-659-9845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9401498
License Number StateNC

VIII. Authorized Official

Name: DR. WARREN STACKS
Title or Position: OWNER
Credential: MD
Phone: 336-659-9440