Basic Information
| Provider Information | |||||||||
| NPI: | 1184672289 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STALCUP | ||||||||
| FirstName: | OBIE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2804 N LOOP 289 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794151410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067447223 | ||||||||
| FaxNumber: | 8067403325 | ||||||||
| Practice Location | |||||||||
| Address1: | 4515 MARSHA SHARP FWY | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794072520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067447223 | ||||||||
| FaxNumber: | 8067403325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | D1064 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 5943079 | 01 | TX | AETNA | OTHER | 099733004 | 05 | TX | MEDICAID | 124642101 | 01 | TX | FIRSTCARE | OTHER | 8V8699 | 01 | TX | BCBS | OTHER | P00333606 | 01 | MEDICARE RAILROAD | OTHER | 124642101 | 01 | TX | TEAM CHOICE - CORE | OTHER |