Provider Demographics
NPI:1679596423
Name:STACKS, KEVIN B (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:B
Last Name:STACKS
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 1:864 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-0775
Mailing Address - Country:US
Mailing Address - Phone:903-624-6514
Mailing Address - Fax:
Practice Address - Street 1:864 PRESTON RD
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-0775
Practice Address - Country:US
Practice Address - Phone:903-624-6514
Practice Address - Fax:903-709-0104
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7908207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102719507Medicaid
TX8A9554OtherBLUE CROSS BLUE SHIELD
TXP00233019Medicare PIN
TX8C7794Medicare PIN
TX8A9554OtherBLUE CROSS BLUE SHIELD