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Organization
RUSSELL STACKHOUSE MD PA
Active
Organization
RUSSELL STACKHOUSE MD PA
Active
Other names
Coastal Vision Center
Organization subpart
No
Provider details
NPI number
Authorized official
NICHOLE RENE BARNETT (PRACTICE ADMINISTRATOR)
(904) 261-5741
Entity
Organization
Contact information
Practice address
6 S 14TH ST, FERNANDINA, FL 32034-3212
(904) 261-5741
(904) 261-7383
Mailing address
6 S 14TH ST, FERNANDINA, FL 32034-3212
(904) 261-5741
(904) 261-7383
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
ME117902
FL
207XX0004X
Orthopaedic Foot and Ankle Surgery Physician
—
NULL
207XX0004X
Orthopaedic Foot and Ankle Surgery Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
070583
DATE OF BIRTH
—
Enumeration date
07/08/2018
Last updated
12/13/2022
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