Provider Demographics
NPI:1093781569
Name:STACEY, JOANNA (MD)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:STACEY
Suffix:
Gender:F
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-4404
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:254-724-7603
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1904207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010079128Medicaid
VA010079136Medicaid
VA1093781569Medicaid
VA004943C19Medicare PIN
VA010079128Medicaid