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General NPI Number Information
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NPI Number | 1952569626
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Entity Type | Individual
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Provider Name | JOHNNY DALE STACKHOUSE DO
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Gender | Male
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Dates
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Enumeration Date | 05/29/2008
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Last Update Date | 07/14/2016
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Provider Practice Location Address
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Address Line | 910 S DONAHUE DR
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City | AUBURN
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State | AL
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Zip | 36832-2975
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Country | US
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Telephone | 334-442-4012
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Fax |
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Provider Business Mailing Address
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Address Line | 910 S DONAHUE DR
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City | AUBURN
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State | AL
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Zip | 36832-2975
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Country | US
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Telephone | 334-442-4012
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | DO.1476
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License Number State | AL
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