Provider Demographics
NPI:1548256977
Name:STACK, FREDERICK RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:RICHARD
Last Name:STACK
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 1:6909 EAST RAY ROAD #15-114
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226
Mailing Address - Country:US
Mailing Address - Phone:520-421-1122
Mailing Address - Fax:520-421-0751
Practice Address - Street 1:801 5TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1326
Practice Address - Country:US
Practice Address - Phone:712-279-2010
Practice Address - Fax:712-279-2034
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24459174400000X
MT0002050207R00000X
IAMD-46368207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ436693002Medicaid
AZAZ0866740OtherBLUE CROSS BLUEE SHIELD
AZ110208816OtherMEDICARE RAILROAD
AZ110208816OtherMEDICARE RAILROAD
AZ436693002Medicaid
AZZ62199Medicare PIN