Provider Demographics
NPI:1699881573
Name:STILLERMAN, JAMES (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:STILLERMAN
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 1:165 COLEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2217
Mailing Address - Country:US
Mailing Address - Phone:315-755-2024
Mailing Address - Fax:
Practice Address - Street 1:165 COLEMAN AVE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2217
Practice Address - Country:US
Practice Address - Phone:315-755-2024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226115208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02370836Medicaid
NYRA4510Medicare PIN
NY020054042Medicare PIN
NYA59697Medicare UPIN