Provider Demographics
NPI:1053351247
Name:STATHAKIOS, JAMES JR (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:STATHAKIOS
Suffix:JR
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 1:3400 FLECKENSTEIN RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3042
Mailing Address - Country:US
Mailing Address - Phone:810-877-7370
Mailing Address - Fax:810-230-9338
Practice Address - Street 1:3400 FLECKENSTEIN RD
Practice Address - Street 2:SUITE 1
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3042
Practice Address - Country:US
Practice Address - Phone:810-877-7370
Practice Address - Fax:810-230-9338
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJS063353225400000X
MI4301063353174400000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI103517420Medicaid
MIP03870001Medicare PIN
MIP03860001Medicare PIN