MEDICARE: JONATHAN STACKPOLE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	A68879	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00A688790	OTHER	CA	BLUE SHIELD OF CA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558347179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN STACKPOLE MD

Provider Business Mailing Address
First Line	:	PO BOX 7096
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95267-0096
Country	:	US
Telephone Number	:	209-956-7725
Fax Number	:	209-956-7733

Provider Business Practice Location Address
First Line	:	23625 HOLMAN HIGHWAY
Second Line	:
City	:	MONTEREY
State	:	CA
Zip	:	93940-5902
Country	:	US
Telephone Number	:	831-624-5311
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2005
Last Update Date	:	12/29/2011

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