Provider Demographics
NPI:1043232101
Name:STANKO, SHELLEY BUNDY (MD)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:BUNDY
Last Name:STANKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7835
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:175 CITY HILL DR
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-3037
Practice Address - Country:US
Practice Address - Phone:606-877-2050
Practice Address - Fax:606-877-2080
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38962207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4000501OtherMEDICARE LAB GROUP
KYCB8799OtherRR MEDICARE GROUP
KY37903705OtherMEDICAID LAB GROUP
KYP00145375OtherRR MEDICARE PIN
KY64091309Medicaid
I20110Medicare UPIN
KY0326323Medicare ID - Type Unspecified
KY37903705OtherMEDICAID LAB GROUP