Provider Demographics
NPI:1154136778
Name:STUBBLEFIELD, MARK DALE
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DALE
Last Name:STUBBLEFIELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENESAW
Mailing Address - State:NE
Mailing Address - Zip Code:68956-1512
Mailing Address - Country:US
Mailing Address - Phone:402-469-9034
Mailing Address - Fax:
Practice Address - Street 1:611 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:KENESAW
Practice Address - State:NE
Practice Address - Zip Code:68956-1512
Practice Address - Country:US
Practice Address - Phone:402-469-9034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor