Provider Demographics
NPI:1487690186
Name:STAM, MARC DENTON (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:DENTON
Last Name:STAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:M
Other - Middle Name:DENTON
Other - Last Name:STAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-347-4662
Mailing Address - Fax:
Practice Address - Street 1:1102 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3503
Practice Address - Country:US
Practice Address - Phone:417-347-5001
Practice Address - Fax:417-347-2477
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101224774208G00000X
ARE-9841208G00000X
CODR.0054365208G00000X
MO2024015247208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010055431Medicaid
ND15573Medicaid
VA010055431Medicaid
VA00X428W02Medicare PIN
NDN718403Medicare PIN
NDN715938Medicare PIN
E84682Medicare UPIN