Provider Demographics
NPI:1033523337
Name:STACEY, XAVIER RAJAGOPAL (MD)
Entity Type:Individual
Prefix:
First Name:XAVIER
Middle Name:RAJAGOPAL
Last Name:STACEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9205 SW BARNES RD
Mailing Address - Street 2:SUITE 20
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6603
Mailing Address - Country:US
Mailing Address - Phone:503-216-2229
Mailing Address - Fax:
Practice Address - Street 1:9205 SW BARNES RD
Practice Address - Street 2:SUITE 20
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6603
Practice Address - Country:US
Practice Address - Phone:503-216-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPG169255207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPG169255OtherOREGON M.D. LIMITED LICENSE