Provider Demographics
NPI:1609886936
Name:STALEY, HOMER LEE (MD)
Entity type:Individual
Prefix:DR
First Name:HOMER
Middle Name:LEE
Last Name:STALEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:104 N LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38464-3734
Mailing Address - Country:US
Mailing Address - Phone:931-762-6476
Mailing Address - Fax:931-762-1841
Practice Address - Street 1:104 N LOCUST AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-3734
Practice Address - Country:US
Practice Address - Phone:931-762-6476
Practice Address - Fax:931-762-1841
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD008952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3170118Medicaid
TN3170118Medicaid
TNB03386Medicare UPIN