Basic Information
| Provider Information | |||||||||
| NPI: | 1649432840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STALLARD | ||||||||
| FirstName: | GRAYDON | ||||||||
| MiddleName: | FRANK | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2555 COURT DR SUITE 270 | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274223477 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2555 COURT DR | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280542134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046717652 | ||||||||
| FaxNumber: | 7046717656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2008 | ||||||||
| LastUpdateDate: | 06/04/2014 | ||||||||
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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 | 208600000X | 5101017931 | MI | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 2014-01062 | NC | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.