Basic Information
| Provider Information | |||||||||
| NPI: | 1053351247 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STATHAKIOS | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 FLECKENSTEIN RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485073042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8108777370 | ||||||||
| FaxNumber: | 8102309338 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 FLECKENSTEIN RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485073042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8108777370 | ||||||||
| FaxNumber: | 8102309338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 11/12/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | JS063353 | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 174400000X | 4301063353 | MI | Y | Other Service Providers | Specialist | 208100000X | 4301063353 | MI | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 103517420 | 05 | MI | MEDICAID |