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
—
—
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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