Provider Demographics
NPI:1083052245
Name:STALLARD, STACEY ANNE CRANDALL (DO)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:ANNE CRANDALL
Last Name:STALLARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 N LOOP 1604 E
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-2303
Mailing Address - Country:US
Mailing Address - Phone:210-375-7790
Mailing Address - Fax:
Practice Address - Street 1:3510 N LOOP 1604 E
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247
Practice Address - Country:US
Practice Address - Phone:210-375-7790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR8278207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology