Provider Demographics
NPI:1043272032
Name:CHIDESTER, STACY ALLEN (DC)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:ALLEN
Last Name:CHIDESTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5144 COLLEGE CORNER PIKE STE A
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45056-1068
Mailing Address - Country:US
Mailing Address - Phone:513-524-4800
Mailing Address - Fax:513-523-8631
Practice Address - Street 1:5144 COLLEGE CORNER PIKE
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:OH
Practice Address - Zip Code:45056-1068
Practice Address - Country:US
Practice Address - Phone:513-524-4800
Practice Address - Fax:513-523-8631
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2292111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000074780OtherANTHEM
OHCH0807053Medicare PIN