Provider Demographics
NPI:1962409466
Name:STOCKRAHM, JON LEE (DO)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:LEE
Last Name:STOCKRAHM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2223 WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-3305
Mailing Address - Country:US
Mailing Address - Phone:812-235-7252
Mailing Address - Fax:812-235-7176
Practice Address - Street 1:2223 WABASH AVE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-3305
Practice Address - Country:US
Practice Address - Phone:812-235-7252
Practice Address - Fax:812-235-7176
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002047207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000211750OtherANTHEM
IN5902718OtherAETNA
IN200227720AMedicaid
IN110232365OtherRAILROAD MEDICARE
IN186170Medicare ID - Type Unspecified
IN000000211750OtherANTHEM
IN258530FMedicare PIN