Healthcare Provider Details

I. General information

NPI: 1689824617
Provider Name (Legal Business Name): JEFFREY STILLMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 10/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 PRATT DR
VESTAL NY
13850-3841
US

IV. Provider business mailing address

PO BOX 931
VESTAL NY
13851-0931
US

V. Phone/Fax

Practice location:
  • Phone: 845-803-2391
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number183994
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number183994
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: