Basic Information
| Provider Information | |||||||||
| NPI: | 1043278260 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STANKARD | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11945 SAN JOSE BLVD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322231613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043961725 | ||||||||
| FaxNumber: | 9043991717 | ||||||||
| Practice Location | |||||||||
| Address1: | 1658 ST VINCENTS WAY | ||||||||
| Address2: | #210 | ||||||||
| City: | MIDDLEBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320688446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042148161 | ||||||||
| FaxNumber: | 9042148164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 11/16/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME56957 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 020039756 | 01 | FL | RAILROAD MEDICARE | OTHER | 205862 | 01 | AVMED | OTHER | 5196465 | 01 | AETNA | OTHER | 1705048 | 01 | CIGNA | OTHER | 25097 | 01 | BCBS FL | OTHER | 274937800 | 05 | FL | MEDICAID |