Provider Demographics
NPI:1689661647
Name:STOVER, JOHN WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:STOVER
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 1:6908 OERSTED RD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-6573
Mailing Address - Country:US
Mailing Address - Phone:505-205-1273
Mailing Address - Fax:
Practice Address - Street 1:6908 OERSTED RD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-6573
Practice Address - Country:US
Practice Address - Phone:505-205-1273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0155207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A79708Medicare UPIN
OHST084784Medicare ID - Type Unspecified