Provider Demographics
NPI:1144212085
Name:STACEY, DOUGLAS S (DPM)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:S
Last Name:STACEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10561 JEFFREYS ST
Mailing Address - Street 2:#110
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4266
Mailing Address - Country:US
Mailing Address - Phone:702-456-3668
Mailing Address - Fax:702-456-6688
Practice Address - Street 1:10561 JEFFREYS ST
Practice Address - Street 2:#110
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4266
Practice Address - Country:US
Practice Address - Phone:702-456-3668
Practice Address - Fax:702-456-6688
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8601213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVT48844Medicare UPIN
NV38610Medicare PIN