Provider Demographics
NPI:1447343678
Name:DOUMAS, STACY J (MD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:J
Last Name:DOUMAS
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 1:3535 ROUTE 66
Mailing Address - Street 2:BUILDING 5
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-2622
Mailing Address - Country:US
Mailing Address - Phone:732-643-4350
Mailing Address - Fax:732-643-4398
Practice Address - Street 1:3535 ROUTE 66
Practice Address - Street 2:BUILDING 5
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-2622
Practice Address - Country:US
Practice Address - Phone:732-643-4350
Practice Address - Fax:732-643-4398
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA080003002084P0800X
NJ25MA080003002084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ108683C7FMedicare PIN