Provider Demographics
NPI:1871586628
Name:DAVID R. STACY, O.D., L.L.C.
Entity type:Organization
Organization Name:DAVID R. STACY, O.D., L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:STACY
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:480-899-0188
Mailing Address - Street 1:2974 N. ALMA SCHOOL ROAD
Mailing Address - Street 2:#3
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-6713
Mailing Address - Country:US
Mailing Address - Phone:480-899-0188
Mailing Address - Fax:480-899-0199
Practice Address - Street 1:2974 N. ALMA SCHOOL ROAD
Practice Address - Street 2:#3
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6713
Practice Address - Country:US
Practice Address - Phone:480-899-0188
Practice Address - Fax:480-899-0199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ#224152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0249770OtherBCBS
AZ035354Medicaid
AZ035354Medicaid
AZ5701050001Medicare NSC
Z0000PFDVJMedicare ID - Type Unspecified
ZWDBNWMedicare PIN
AZ0249770OtherBCBS