Provider Demographics
NPI:1154557536
Name:CHISM, STANLEY (MD)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:CHISM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 MADRONO AVE
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-1018
Mailing Address - Country:US
Mailing Address - Phone:650-322-6332
Mailing Address - Fax:
Practice Address - Street 1:1635 MADRONO AVE
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-1018
Practice Address - Country:US
Practice Address - Phone:650-322-6332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-30
Last Update Date:2009-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC307172085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA34341Medicare PIN