Provider Demographics
NPI:1063499895
Name:SMITHSON, MD, STACY L (MD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:L
Last Name:SMITHSON, MD
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 1:1621 W MORRIS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37813-2967
Mailing Address - Country:US
Mailing Address - Phone:423-492-7100
Mailing Address - Fax:
Practice Address - Street 1:1621 W MORRIS BLVD STE A
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37813-2967
Practice Address - Country:US
Practice Address - Phone:423-492-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18049174400000X, 207V00000X
ORMD198221207V00000X
NH22067207V00000X
TN68868207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCI80496Medicaid
SCGP3644Medicaid
TNQ084683Medicaid