Provider Demographics
NPI:1558347179
Name:STACKPOLE, JONATHAN (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:STACKPOLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JON
Other - Middle Name:JEFFREY
Other - Last Name:STACKPOLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:23625 HOLMAN HIGHWAY
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-5902
Practice Address - Country:US
Practice Address - Phone:831-624-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68879207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A688790OtherBLUE SHIELD OF CA
CA00A688790Medicaid
CAP00337886Medicare PIN
CA00A688790Medicaid
CA00A688790OtherBLUE SHIELD OF CA
CA00A688793Medicare PIN