Provider Demographics
NPI:1083877278
Name:BASS, STACEY A (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:A
Last Name:BASS
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:DR
Other - First Name:STACEY
Other - Middle Name:A
Other - Last Name:TROTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:PO BOX 208042
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520-8042
Mailing Address - Country:US
Mailing Address - Phone:203-298-8967
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-298-8967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0528492085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology