Provider Demographics
NPI:1730162785
Name:STANLEY, GEORGE A (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:A
Last Name:STANLEY
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 1:111 N LAKEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3213
Mailing Address - Country:US
Mailing Address - Phone:407-975-3315
Mailing Address - Fax:407-622-0849
Practice Address - Street 1:111 N LAKEMONT AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3213
Practice Address - Country:US
Practice Address - Phone:407-975-3315
Practice Address - Fax:407-622-0849
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME583442085R0202X
MO200400119752085R0202X
NC2004002672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054263600Medicaid
FL12480Medicare ID - Type UnspecifiedMEDICARE
FL054263600Medicaid