Provider Demographics
NPI:1194784256
Name:CHASTAIN, STEPHEN LACKEY (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LACKEY
Last Name:CHASTAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:STEPHEN
Other - Middle Name:LACKEY
Other - Last Name:CHASTAIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:9611 N US HIGHWAY 1
Mailing Address - Street 2:#166
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-6363
Mailing Address - Country:US
Mailing Address - Phone:772-581-3990
Mailing Address - Fax:772-581-3991
Practice Address - Street 1:5850 SE COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-6420
Practice Address - Country:US
Practice Address - Phone:772-324-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-18
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00014657207R00000X
SC33627207R00000X
FLME114042207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL00083765Medicaid
SC336274Medicaid
AL51083765OtherBLUE CROSS BLUE SHIELD
AL110050545Medicare PIN
E20750Medicare UPIN
AL00083765Medicaid
SC336274Medicaid