Basic Information
| Provider Information | |||||||||
| NPI: | 1811960958 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STOCKAMP | ||||||||
| FirstName: | KURT | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 BELFORT RD | ||||||||
| Address2: | STE 4015 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322163623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044506014 | ||||||||
| FaxNumber: | 9044506401 | ||||||||
| Practice Location | |||||||||
| Address1: | 5147 N 9TH AVE | ||||||||
| Address2: | STE. 203 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325048771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504766110 | ||||||||
| FaxNumber: | 8504796042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME64368 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 18969 | 01 | FL | BCBS | OTHER | 372995800 | 01 | FL | MEDICAID | OTHER | 009935384 | 01 | AL | AL MEDICAID | OTHER | 59101757 | 01 | AL | BCBS | OTHER |