Provider Demographics
NPI:1871596718
Name:STALLKAMP, VANESSA L (MD)
Entity type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:L
Last Name:STALLKAMP
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 1:830 W HIGH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-3968
Mailing Address - Country:US
Mailing Address - Phone:419-227-9354
Mailing Address - Fax:419-228-3273
Practice Address - Street 1:830 W HIGH ST
Practice Address - Street 2:STE 101
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-3968
Practice Address - Country:US
Practice Address - Phone:419-227-9354
Practice Address - Fax:419-228-3273
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3506935207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2018328Medicaid
OH000000207541OtherANTHEM BLUE SHIELD
OH160046611OtherRAILROAD MEDICARE
OHST0822853Medicare ID - Type Unspecified
OH2018328Medicaid